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- 1 Industry"tit.-rykss I7ltisitrrt Cyarnts <br /> 141X)L Washington A%e <br /> t 1'.0.i3ttx 7162 ri? 't'.Se f,tal s trtl#s 73t a <br /> t Madison.W1537W--7162 6 � <br /> 3s»2- <br /> State T attsactiur.art tt - _ __ _ <br /> Sanitary Permit Application 106 s �. <br /> ITS- p524- <br /> } in a€cordamc with SPS 393-21(2).tt:i5.:'rtlm of-this fi-wm tat the appropriate unit 4_ _ <br /> is required prior to obtaining a sanitary"permit Late Application forms for state-owned POWI S are submitted to Project Addreas(it d .e€nt u rt mailing awress) <br /> the Department of Safety and Professional Son izes.Personal information you provide may N used for secondary �in xcor-Mnre vNith the Pr-Aa i.a:y,s, 15. l ilml..S=-s. ! ?.'51 M A LLAXp LAKE <br /> I. A40it1fign Information-Pk'sse Print All Isrformatisrt --�� _ __ -,MAD � <br /> tirr;cl. <br /> Property Oyyner'.s'vamo -J�3q-4 <br /> r- <br /> �t�,tCE �. f To1m#A �. Eta 000-of loon <br /> I'tx pest±'Chvrwr's NIZA ng Address privenw location <br /> 11 34q JON ST .IV W ( Go't.lot <br /> {s~iry.Srate f�nCrx:c j PhoneNutnt-.-t �� l,� C� r. S.U. 34 <br /> f <br /> # Cw RAPIDsi /K1 6543 3 �# 3 rele ow t <br /> _ - - - --------� — -- — .i 51 - 15 Mao <br /> - <br /> IL Type of Building(check all that apply) Lot= i <br /> are PailsDasxtlim;-`wmaix�ofBair.unu___-_ Subdiv sion Name <br /> iirrt€ic? 1 { <br /> I }PublieCommercial-Dtwrity Use of <br /> ( U 4 try <br /> i CShI%--M bLr t`-J Vill of <br /> slaw owr-d-Describe. so <br /> l <br /> III.Type of Permit:- (Cheek only om box ou line A. Comphat line R if applicable) <br /> 1 i ?\zyk Sister Rq ac--ement SL;tem leldirt_Tani:Rtpia.`e n,(Ditty i-i mo&k-atiam to rNisung Sysrtrat(txViair.) <br /> R• Permit Remwd ❑Hermit Revtsion Q€lyartge of Plurntxr Q Permit Trans*r to Neyy � List Pre'taus Permit Number and t?ate i�sttai <br /> setbre laspirtatzoen ; ihytxr ! <br /> W.Type of Pt'WUS Systera1Com nent/Ms ice: Check all that apply) # <br /> D ivrott-Pressurized In-Ground 13 Fressurzcc it U a;ad El At-Grade V wkwni>24 in of suiteble.sa l Slot nd<24 in of suitable sail <br /> O Nordin g l aft t{Dth. l3ispets ai Zumpelnerrl(c S t�.`---------- F 1 Prewavm t Fks is(e. -n) <br /> V.DhoersaMeatwent Area Inlonnation: <br /> Design Flow(gpd) I Design Soil Application Ratc(spdsf) # Dispersal Area Required(sty Dupersal Area Pro d(st) System Elezation <br /> 450 11 0.19 i 1227,50 2z'7. 9 SO <br /> VI.'Faak Into Capacity in Total J or i Afanuf4ouivx <br /> Crdlluru Gallons Units j ! <br /> g NC Taut; <br /> Sept .--it.&.Jza <br /> W i i <br /> tl'asinz Cn.+rnbCr r /�F� /_L/1 i 1 t <br /> VII.Regwwibitity Stateartent-),the etsdtrsignerL asst€- ra p""bilita for iestsls'Qties of the POUTS she-An on 0 w attached pleas. <br /> Plumber's Name(Print) Plum 13usiness Phone N=)-vr j <br /> Plumber's Addream.(Street.City.Siatea Zip Code;l ^� <br /> Z�'L r--F;ME K <br /> 1'III.CountvlBe rtms:rtl i'se dale <br /> A}rnn cxI 7 OisgrmPd --- (( l i?art fss sod i Lciuing Agtr€t S <br /> 0 Oywmer Giaen Reason for D'rua! ( 3 ZS Z! i <br /> j IX Conditions of ApgrayaltReasons for Dicxpprovul T <br /> t, <br /> i <br /> nnL E Q d C <br /> Asw�1 tctomgain t.ians f riae ss $,sad sab�js.r to stae L'.vc.sn aat9���.e-,z.;;&;,taus S i.2 x 1 t" s' <br /> MAY 18 2021 <br /> SADdi39A iRa teA%l.l) <br /> � Burnett County <br /> i <br /> Land Services Department <br />