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fL f. \�' industry Services t�icrisiott /J//� <br /> f T.{ <br /> rig(r, vs .. Si <br /> • 1400E Washington Ave t Sas}iila(rr�t'e //it Number(to be filled in by Ca. <br /> y, 4j <br /> Zi P.L'i.sit i,sa „t` a`itp ,. Madison,WI 53707-7162 <br /> J ,,.L I '2q-71, &) E53g <br /> Sanitary Permit Application. S e Transaction Number <br /> in accordance with SPS 33321(2)„'Avis.Ache.Cot stt on of this fonts to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Now Application forms for state-owned POD aft submitted to <br /> the Department of SafetF and Profess}o+wl Saviors. Pasamai information you provide maybe used for secondary, i Project Ad dres(if differem/has mailian addn <br /> purposes in accordance with the Privacy Law,s_15d31(I)(in).Stats. # U <br /> I. Application Information-Please Print All Information i 7 yigp2 c t/' <br /> Property Owners Name I Parcel <br /> r-r�K. I o. 2I7 <br /> y2 IT�`� � o3� - yy/ 4o - /lac <br /> Property Owner's Marlins Address r Property Location <br /> 71 3 go AWE, <br /> ! Govt.Lot <br /> City,StateZipCode Phone Number <br /> fin► 5!'�� _ 5 c��._NE:, Section 1l� <br /> _ <br /> sue/ ! 71 S.S' ' CPS , � / R/ `` E_o <br /> 7 = <br /> IL Type of Building(check all that apply) # Lot= 1 <br /> 20 I or2 Family DcreIli -Number 0Q ad/emus 1 f ,�, Subdivision Name <br /> C-6 - vF_N/E/ucF J31N-rt-t - crietizrecrgi ci Pubhc!Coo-}}merciai-Describe Use Block g — <br /> 0 State Owned-Describe Use —1 0 City of <br /> CSM Number ! a Villas. of <br /> E <br /> I ! K Tows}of <br /> III.Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A. A New System 0 Replacement System 0 Treainient/Holding Tar&Replacement Only 1 El Other Modification to Es-istinc System(erg <br /> s <br /> B. 0 Permit Renewal 0 Permit Revision. D Chan se of 1 n Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber 1 Owner <br /> t <br /> IV.Type of POWTS SysteuriComponent/Device_ (Check all that apply) <br /> El Noti-Pressnriaed hi-Orouxd 0 Preturized In-Ground 0 At-Grade 0 Mound>24 In.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Disper alffreatrnent Area Information: <br /> D sinrr Flow(mod) Design Soil Application Dispersal Arta Required(ssi) i Dispersal Area Proposed(sf) I System Elevation <br /> So Rant 0 3O0 1 300 19 7, Jo r <br /> VI.Tank Info Capacity in I I I <br /> Gallons Total €of 1 ^ 4 <br /> Mann ^ ^ ' j 1 Y <br /> tI Gallons I Units l _ - u <br /> Z:l{1�3�i , hsasttri:talus 3 j " { <br /> ^�J f — I f :- V <br /> • i E <br /> Septic or Holding Tani: f /OGCD I 1/62:30i 1 j 51`CO LA-7- t ID ID ID <br /> Dosing Chamber 1 j i 1 1 0 i © ID ID <br /> VII.Responsibility Statement-I,tile nude)4gited,assume responsibility far installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber t_rtatur - _ y 3iP/MPRS Number Business Phone Number <br /> 5 K -D Y araAel i a07035-? 7/3--766--)-°' <br /> Plumber's Address(Street,Cite,State_Zip Cork) <br /> 7c,3 804 -LJt /i1-14--i( r t-tz, s-yo o f <br /> VIII.ConntviDepartment Use Only <br /> r nrc}vzti ❑D oyes) Permit FLY fiat Issu f Issnino Aa,x}i Si�iature <br /> 1g, }repot $ 7Z 5 15 ! _ <br /> 0 Owner Given Reason for Denial t 7 Z� �G�- c. <br /> IX.Conditions of Approval/Reasons for Disapproval C -11 T/75 ���€5 <br /> i 114-e-t-4- ca lz-/-6,4s <br /> Follow court-ky � a-k rl s� re i ire:atu <br /> Attach to complete plans for the s�saw and submit to the Cavan:only no paper not Less then S trt s I 1 b 2C 4 <br /> g <br /> Burnett County <br /> Land Services Department <br />