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Co <br /> amY <br /> Industry Services Division �c�rn o i� <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> F 1 P.O.Box 7 <br /> r' Madison,VVI 5370707-7162 <br /> Sanitary Permit Application Stam Tmmaclion Nwnber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis f to the appropriate governnmtai unit <br /> is mluired prior to obtaining a sanitary permit Nom:Application f rms for smtoewned POW Bare submined to Project Add.,ffiffffioneat than mailing address) <br /> the Dcpanmcnt of Safety and Prof sional Sr,ies. Pemowl information you provide may be used far second'ary <br /> .nuore with de Pnvae taw,..15,0,1(l)(rd,Stara. �`138" Sy/eel /7G/ <br /> 1. Application Information-Please Print All Information <br /> Pmperty Owners Name PlParcel 070 9.1aI0r4roSoSoo/ <br /> lgl<x 0 /8mo <br /> Property Owner's Mailing Address Property Location <br /> l�J <br /> 1S310 rawte✓s Z" Cf tale A✓ Gon.Lot I _ <br /> City,Slam Zip CMB Phone Ntmber F, %, Section /Q <br /> / r1� S.5-O$d (circle one) <br /> s`/t✓°{-.� T G/O N; R /y_EorD <br /> H.Type of Building(check all that apply) 1 1-mN <br /> �.I or Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block q <br /> ❑PubOrlCormuercul-Describe Usc 0 City of <br /> C1 State Owned-Desenbe U. CSM Number ❑Villageaf .aL <br /> 0Townof .SCs/r <br /> III.Type of Permit: (Check onlyane boson line A. Complete line B if applicable) <br /> A. 11 Now Sysmm f `eplacormmt System ❑'fre.tAklding Tank Replacement Only ❑OtherMMifiwtiov to a rm-&Sydem(expum) <br /> R. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑P mmit Trmufa m Ncw Lin Prevwm Permit Number and Dam Iswd <br /> Before Eapimtfn Ci vncf <br /> IV.Type of POWTSS stem/Com o ent/Device: CM1eck all that apply) <br /> ❑ Nov-Pressurized In-Groand ❑ Pmssurizd In-0muod ❑ AtGhade ❑Mound>24 m.ofsuitablesoil ❑ Mound<24 in.ofsuitable soil <br /> Holding Tmrk ❑Order Disprsal Comporaat(explain) ❑Prebehncat Dxvcc(explain) <br /> V.Dis ersal fremment Area Information: <br /> Deign Flow Qmd) Design Soil Application Rateg also Dispersal Area uimd(SO Dispersal Ana Pmposd(sty System Elevation <br /> 300 — <br /> VI.Tanklnfo Capacitym Tbtal Nor Manufazmrer <br /> Gallo. Gallo. Units $ <br /> New Tnolu Fluting Tents y 2 u. '�' <br /> iVoi Zt uU <br /> sePde ar nakwerwr• dSpe d.5>o I Gv/PS er K <br /> Daring Chamber <br /> VII.Responslbllity Statement- [,the undersized,asmme responsibility for maidtation of the POWTS shown on the attached plans. <br /> Pliaolar's Name(Print) <br /> JMAmbeRawss PoNber <br /> 7 /S <br /> Plunbm's <br /> 7 <br /> Address(S City,State,Zip Code) <br /> 7450 1<— 3S <br /> V111.Count /De artment Use Only <br /> APprovd ❑ Disappmvd Permit 1'. Date Issued Issuing Agat Signature <br /> ❑Gwnercivenxramnr Uatal <br /> IX.Conditions of ApprovaVRemo d,for Disapproval '7� �ilff x <br /> ,(C, )r V � 2� �fl JUN 2 D 2014 MAY 0 2014 <br /> I <br /> 1 <br /> Anvramevmak¢pnm foraexydem ua�wml[mrar Cvusry oelyoe paper vm kp vtx 11ly <br /> VVINETT <br /> ZONING <br /> COUNTY <br /> BURNETT COUNTY ZO <br /> SBD-6398(R0313) <br /> ZONING <br />