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ai'x'�:.. County <br /> �.;'n :• Industry Services Division a„aP-//- <br /> f .. 1400 E Washington Ave Sanital' mit Numher ws heti Iled in by Co.) <br /> 1S.PS' i'1 P.o.eo><nsz ry a5�733t-f- <br /> •v: �. <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application Sla,Trans„"onNumber <br /> in accordance with SPS 18321('-).tvis.Adm.Code.submission of has torn to the appmmi ne governmental unit <br /> is mplired prior in obtaining a sanitary pRman Note:Application forme lar sate-owned POUTS are Imadined m Proj/ect Address lifdillerem than nailing addrtss) <br /> the Department ol'Salety and Pro@ssiotul Servles. Penorul information you provide may be used for secondary -j68y <br /> in conhnee with the Privacy Law,s. 15.M11)(m).Slurs. 0 <br /> 1. A sclication hJofm ation-Please Print All Information <br /> Pmlxnm Owner's Name Parcel, /6-.16-5/S <br /> /� / -I—X 07- oto-i.- YO- <br /> i. <br /> Proper,Owner's Mailing Address podia,Local <br /> 8 756 E. Yr!/e w AP, Govt.Lm <br /> City,State lip Cade Phone NumlxY JF '/.. ',•. Section etb <br /> WS <br /> SN P3Ode nue) <br /> 11.1'spe of 6udding(checkai <br /> ll that kinds) Letp T � O N; R14 Eor6C7 <br /> �I or_family Dwell ing-Numher of Petticoats O 7 Subllnieion Nam <br /> Cw�aJc w yap vY LAILANntG 9Db. la vItLR 46d <br /> block d YELCOW LRKE <br /> ElPublic Commercial-Dscribe Use ❑Cin of <br /> ❑Sum Owned-Dc.be 0. CSM Number ❑ Villogc of <br /> RFo.anf Gak/•��- <br /> Ill.'I'vpe of Permit: (Check only one hot on line A. Complete line U if applicable) <br /> A Gg]]New� 1 ❑ Rel IS t <br /> N”, ys ern pav'cnten System ❑TrmlmrnVlfnlJing lank Replacement Only ❑ Other Alodilicainn to F.aisting Systmm(explain) <br /> R. ❑ Permit Renewal ❑ Permit Re,carn ❑rhanki,of Plumber ❑Permit Transfer to New List 1'mvious P—al Numhrand hale Issued <br /> Ddi.re E'na'ali I Owner <br /> 1 V.Tr a of PO\V1'S SrvemlCnm onentlDevicc Cheek all that apply) <br /> 9N..-Presm,na]a Gmund ❑ Pre sumed In-Ground ❑ AI{'rade ❑Mmad>__'4 in,ofsuitahle sail ❑ 1lound<Y-oI'sonable soil <br /> ❑ Holding'I'ank ❑Other Dispersal Con,weenl(explain l Pretreat ant Device(explain) <br /> V.Itis ersal7l'reatmem Area Information: <br /> Design];law host Design Soil Application Ratexoscsl) Uizpvrsd Arca Removal(at) Dispersal \na Proposed ls0 Sysam lllevation <br /> 700 , S 600 Goo y;J, -7 <br /> VI.Tank Info Capacity in Ima1 4 o Manufacmry y <br /> Ga11om Gallon Units - u <br /> Sew lanks F,xhli�Trnks L o_ d. d <br /> S'lavorunlding lank / wArs .� X <br /> WsinGCMmbcr <br /> VIL Responsihilit)'SlalemeM- I.Ihe undersigned,w-nox—ixonnbilis for imullaian of the PO\)TS•howm an the mmched plans. <br /> Plumber',Name(Prion Plumhr's Signature MPMIRS Nionber Ba,awss Panne Number <br /> 2,&1c� hie / /2�� 81�6-41/s-� <br /> Maritsa,',Address(Strareb(.Irv,Sum.Zia Cats) <br /> 77ae ?S W-e---4 fv- L✓1 SYBY3 <br /> N'111.CountvlDe arhnent Use Only <br /> \PPreved 11DSx,araved permit Fee Dae Issued Issuing Aback Sibmamre <br /> ❑ Owner Given Reason for Denial <br /> 3ZS.a0 io- a-iy <br /> IS.Conditions of Approval/Reasons for Disapproval <br /> D EUGENE <br /> n SEP S 2014 i <br /> ej -q_/q q, 111111 11 mple4plawfurlhey maMauhmlllnlhe0� ponlr nPaper rlotlesslM1vnXlrtellin <br /> / <br /> BURNETT COUNTY <br /> SED-6398(110313) ZONING <br />