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County
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<br /> Safety and Buildings Division V✓%C
<br /> p 201 W.Washington Ave.,P.
<br /> S O. Box 7162 Sanitary Penni Nmob,,Do be filled,.by Ca)
<br /> PS...` Madison,W153707-7162 lU
<br /> \.,,..>• 555004 W
<br /> Sanitary permit Application State l mmartion Nmnber
<br /> Inaei,acme with SPS 383 2](2),Avia.Ad..Code.,thmissionoflhis form to[lie appropriate goveminentm Out 1` leo
<br /> s nyuirM max,oal ining a smit.,permit. Nolo.Application lama for etateowned POwTS are submimd to Projm Addns(ifiillrnmden mailing addim—)
<br /> the Department of Safety and PmfessiomJ Sent, Pen.wl information you provide may be used for smoni 11 II p u ce iti coNuncewirhihePliv.c Iaw,.a. 15.040)(m),Suns. 417oI. Application Information–Please Print All Information A
<br /> IAKE W
<br /> A
<br /> Property Owne's Name
<br /> Parcel A
<br /> NDN U-C (L.croY Nelson 460747-4,3Qo7 Z 36'1. °8 3o2-C00—D/lpOp
<br /> Property Owner's Mailing Address Property lacmim
<br /> 3&5 Stiff So Gane R, i -Yt M014 O
<br /> City.Stalezip Cede Phone umbar '/•. SW V., Sado. 8
<br /> hell ZaKG W 54e71 Cos) 468. 0325BJH oneta
<br /> 11.Ty pe of Building(check.11 that apply) q LoIP
<br /> IAI or2Fxmilv Dwdling–Numherof Bclmoms ] Subdiviram Name
<br /> Block
<br /> D PuMicCommercial–Describe Um
<br /> ❑ CitY of
<br /> ❑State Ownal–Desedbe llm CSM Number D\'illage.1
<br /> 9 Townmf_ t 6)0`
<br /> 111.Type of Permit (Check only one box on line A. Complete line B if applicoble) –
<br /> `\' )Q Nt,e Sysem D Replacement Synem ❑TreatmanUllolding Tank Replaennent Only D Other Molifiwtion m Exixhng Syuem(cplairl
<br /> B. DPmact Renewal DPmnit Rr—ton ❑Change of Plumber ❑Permit I om,fcr to Ni,. Lis Pr,mit,Perron Number and Date bsmd
<br /> Belim Expiration Owner
<br /> V. Ib pe of PO\VFS SvsteMCom ponentlDevicr. (Cheek all that a Ir
<br /> XNor Poe on,,ed InLround D PresmduJ In-Gmond D At-Grade D Kened 123 inof,ar,ble coil ❑ Mound 124 in.ul'suitable.oil
<br /> D Holding Turf D Other Dispersal Component(explain) D Pmrerpnent He,ice(explmn)
<br /> V.Dis ersal/'I'real, ent Area Information:
<br /> Design Flow(gpd) Design Soil Application Rm jgplsn D&peaal Arcotaired(sQ Disperoal Area Pmpneed(sp System Elmwtian
<br /> 1.56 .7 1 ✓o'f3 Whi4 9�lip 94: 7
<br /> VL'Fvnk Info capachy inTonal #nf >lanuti¢wrcr
<br /> Gallons Gallant, urn,
<br /> N<w TaoAi Exiaing Tanks
<br /> ]Trk fir HOWin6 Fail, l/OU I I Q
<br /> Da,ina Clnmb,,
<br /> VII.Responsibility Statement- I,the undersigned,assume rr,annihilitr far installation of the POeTS show n an the attached Plan:.
<br /> Plumbds Name(Poor) Plumber,5i name MP;MPR56mnber, Businax Phone Number
<br /> Wdhe K.uK/ndh - 2503/8 76-Zb-34O
<br /> Plumber's Address(Street,Ciry.Suns.Zip rx"
<br /> W 19 k41 6. Reads SPRIrJG BQeoK Wt 54OZ
<br /> VIII.Cou nDdDe .rumen,Use On lv
<br /> PT'f""enni,Fee Dam F mod Issuing Age
<br /> Approved ❑ Divppmcd r or
<br /> D ,
<br /> OarrGiveneamDermal 'Rn for Dal S 32– ,� "I
<br /> IX.Condi,ions of A pproval/Reasons for Disapproval
<br /> D
<br /> Awls m mmaloe plim fres,—na.aM ruemommr Coum,..I,un raper no m.man xl n. t mn In 6.
<br /> BURNETT COUNTY
<br /> SBD-6348(R. l l/1 l) ZONING
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