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P-d'sn"318.3 <br /> coumyQIntlustry Services Division wr n'ETf1400 E Washington AverlPO.Box7162Madison, WI 53707-7162 6Sanitary Penult Application <br /> I( ) isi, Ad C I b , Itl '1 Ih ,, p . , tl 1o obc nadnry Penni Non Anpinatio I cru rot nmPONIS 'uM1 n It -JentA1duv Uf d'flerent 01n, myhug oddms) <br /> 1 Safety and YmleUional Servies. Personal information you Plnvide ars,be used for snconMry SAME <br /> accentuate with the Privacy L—,, 15r"L)onl,Scot, <br /> LApplication lnformatimt—plcnse Print All lnfnrmation <br /> Nmpeny owner's Nonni p7,o3d-a'ij 1•CS+19-S-o-d'- <br /> w ; lllavvQ/S6M Bo!- o18m00 <br /> proper,Owva s Mailing Address Nropenr Location <br /> 3p 73'1 /eL Cost Lol1— <br /> cty.Smle .Ulre«m PAoce N"olo,' y, ii, section <br /> DAh54✓v I-✓S SYSBO6/1-SS7- 7 81 � feaaeone <br /> N: It �Fn� <br /> 11.Type of Building(check all thot apple) Lotp <br /> �a ivixirn Name <br /> E] I nr p rmiedr Dweniag-Nrunb..nfeahoon,, <br /> a <br /> 3 <br /> Plock a <br /> ❑Publr,(votmercivl—Describe Use ❑ City of <br /> CSMNumhr ❑ Villagenf <br /> E Ameovood—Desenb,Lse 'Town rf ✓'wrtS <br /> III.r.pe tef Permit (Chv,Rkaa only one ons nn line A. Complete line B if applieahle) <br /> 'A' ❑ New Srstan yes Rcplacenuvn SysLrn ❑ lreaunatUlloldina Tank Replaamem Only ❑Other hlodifirdonro Existing SYztnn(explain) <br /> Ii. ❑ permit Ren wal ❑ I'emrit Ransmn ❑CM1m1e of Nlmnber ❑PcmiYrrunv leer m New List Previous Permit Number and Dole Issued <br /> Bcfare Expiration Owner <br /> 1 I v e of POR"I'S system/Com ronenVDevler: (Check all[hat opal <br /> Nor-Presxonaed InGmmtd E PreasnnµunLmund 11A1-trade E Mound 124 in okailahle a..I EM1loundg4in-ufsuimble sod <br /> E Nolen.,Tmtk ❑Other Ung al Component[expluinl ❑Prenevan:nt Uevia[eaplainl <br /> V.Dis ernauri-vi hnent Area Informntion: <br /> DcsipJ119co,lgpU Design Soil AVPEcminn ltwe(gpdsB Dip eml Arcu Rrquiled fsB D¢pnsvlNrn Ymptzd[sl) Sramo Elevation <br /> 4-- 7 ` Y3 G s� 93. v(. Y <br /> V'I.Tank Info Capacity or Taal #or Maorfacmrer <br /> Gail-, Grillo, Units - _ <br /> evT-1, Exi inpTank, _ _ _ '° <br /> _ n'J - <br /> ,,7,orlmlNap Tonk /Cao /Edd <br /> VII.RexponsibiliN Statement- L the undersigned assume ruepnnsibility for installation of the 1'(1RTS shim on the attached plans. <br /> Plumher's Nmne(Pont) PlmnbcPsslanomre MYIM1IPRS NnmMr Business Phone rasher <br /> jZr�/t o /tel s T* ddSeu-/ �a�8G6-v s 7 <br /> r'lumbu•s Address(Street.cin.Sime.>.iP tale) <br /> 77 <br /> 15' 3.� .v�5sf 1j S56S3 <br /> VIII. 'ours I , nrlmcnt Usc Ooly <br /> Appo—d E D'sapPmved pcmrit Fee Dan Is-ol Issuing Agent Sian wre <br /> 3zS. -219C1 � nc� <br /> ❑ owltercven Ressrn or,tenial s !n - <br /> IS Conditions of Approval/Reasons for Disapproval .. <br /> (/. ,/ Vern 1, splen plan,mer the r myna unman,tae en t nt np+ser.his Ixvn X nt r 1111 <br /> C.S�/ 1 -Y _ j <br /> BURNETT COUNTY <br /> SBD 63 S(110313) ZONING <br />