|
..._..._...,..... _ . ,
<br /> t,Larits".y
<br /> 1;kiNi4.-0 ,vrvfkets.3..)1**4:000;•
<br /> f**Di????4114lettelit?ritX?Y" tat/061-1- c
<br /> ••>-?:a •-y
<br /> .-•. P.O.Box 7162 1 Sanitrini Pemlit Nutilheite lilled in bct-o-
<br /> i
<br /> ' Madison.WI 53707-7162 61)0•1 "-Aa—9 7
<br /> i lics Li 34e7 i
<br /> ,
<br /> State Traumata"!Number
<br /> Sanitary Permit Application NA-
<br /> fl.,.,,:,;,,,,. „,..,„,c,,„. SYS 3K3 21(24 Wis.Alm Coc tim
<br /> k.takimissi.o.ocs foniri to tiny am-corneae gosenunental unit
<br /> is required plies to obtaining a sanitary perrnit.Note:Application forms for state-owned POTS are submitted to Project Address(if diffinent than mailing address)
<br /> the Department of Safety and Professional Services Personal information you Novi&may be used for secondary
<br /> purposes in accor&rice with the Privacy Lass.s 15.04(I Xm).Stats Zcrt5/ SEI 13E gOAT)
<br /> I. Application Information-Please Print All Information
<br /> Property themes Name Parcel 4 07.oiz-z-io./6--07-6-
<br /> KA-n-1 LEE./4/ c. Quo% e5"-011 — 0i101,0
<br /> Property Owner's Mailing Address Property I maim/
<br /> 5557 Fx .m.otsrr Avg 3• Gave Lot i I
<br /> Cir,.Stale l Zit,CULIC
<br /> I - 1 Phone NUntbtx — .h. 'k SeetiOr. ,0 7_
<br /> M pts.i AO) i 6-5-Loci i 715--7cti- II 17(1 . _if° _ 16frircit_ta
<br /> IL Type of Building(check all that apply) 4 1 lot#
<br /> - '
<br /> Asew tin Name 1 or 2 Family Dy.elling-Number of Bedrooms __ 1
<br /> 1 Block 4 NA
<br /> D pubitecommermat-Describe rse —
<br /> 0 City of_
<br /> 1 .
<br /> i CSM Number 0 Village of
<br /> D State ChYried-Describe Use
<br /> I V 1 0 Evil Xr.v.„of TA-CK-Sni\I
<br /> 1 I
<br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) .
<br /> A i r.,,,,,: -
<br /> i i.,..4.ev.system Y.Replacement SNV.ZM 1 O Treatment...11°kb%.Tank Replacement Onls
<br /> 0 other Nloditication to Existing System(explain?
<br /> B. 0 Permit Renewal a Permit Res ision 0 ChangeofPiuinber ; 0 Pemitt Transter to NM ' list Previms'irmit Numb°and Date Issue"
<br /> Before Expiration 1 01:11CT 18 b 1 II 09,D3-qz.
<br /> IV.Type of POUTS SystuniComponentiDes ism (Check all that appI ,
<br /> 3
<br /> 3SaTon-Pressurized In-Ground 0 Pressurized la-Ground CI At-Grade 0 Mislaid>24 as.of suitable soil El Mound<24 in of sultaal. e soil
<br /> „../
<br /> 0 Bolding Tank a Other Dispersal Component(explain) ADi> Fil-TER 0 Pretreatment Dolce(explain)
<br /> V.Dispersal/Treatment Area Infonratiom -9014• Jo cIA.
<br /> Desk?'Flowtopd) i Design Sod Application Rate(fp.kt) I 1Wspmal Area RequiredAsf) 1 Dispersal Area Proposed(sf) 1 System Elm ation /
<br /> 300 1
<br /> ! 0:7
<br /> 1 liz 1.6r
<br /> 1 €15.85
<br /> VI.Tank Info 1 Capacity in I Total 1 =of I Nfanufacturer 1
<br /> 1 .
<br /> Gallons Gall0fiS i LIMES f it i:
<br /> 1 :7: ',.t.-" ZZ': : 1 -7' 1 xi PIII
<br /> New Tasks 1 ENiaiing rank.,k t 1
<br /> Sera,:oei6olelag,:temiz I 'set i
<br /> .. ‹,tvii
<br /> naalaialosaliat 1 ! 1 1 f i
<br /> NIL Responsibility Ststeasent-I,the sunkrsigned,assume responsibility to installation of the POUTS shown on the attached plans.
<br /> Piu ber s Name(Print)
<br /> t i ekyl ,
<br /> A
<br /> a 4i1co 1 PI -r's Sionteure MPASPRS Number i Business Phone Number
<br /> t.tgoil d 7K"6-6'3-8 q09
<br /> Plurri)t),,Attitress(Street,Crty-..Siatc4.ip Code)
<br /> DI,I a co vv.‘ 4-t-e_QA, Luc ri WI: 5-q 3
<br /> VIII.County/Department Use Only —
<br /> brAPPT,nal I 0[Ns:wormed Permit Fee ,ep Date ill tv i 1 • g Agen ignatur
<br /> 0 Ovate/Given Reas-un for Denial 5 37,5 1:',-- 1 51 .
<br /> i .
<br /> IX.Conditions of Approval/RopfordtXprovol
<br /> iheeir C.It
<br /> 1
<br /> i MECEIVE
<br /> ,. riN
<br /> _
<br /> A. ..to complete plain for the eyssenk sail submit to the Corny osky en merino;ton a Pc* UV 17 --r-a.sir .-1.1
<br /> 4 375
<br /> MAY 1 9 2022
<br /> 1
<br /> SI113-61911 tit.03j14) • 6 q 4
<br /> Burnett ounty
<br /> Land Services De•artment
<br />
|