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$rARIN ( Industry Sen-ices Dnitao County <br /> f r I lEtOa Washington nve i DVra <br /> S 1 i r <br /> 1 i i i I Madison,WI 33707-7/62 G HN o?� '— `(to be ailed m by C'loj�t y}5/- <br /> Sanitary Permit Application ► s.Transaction Numher <br /> to accordance with SPS In 21(2),Wu Aden Code.submission of this form to the ipcxm r rc .weyrr+rt*Mar <br /> is required prior to obtaining a sanitary pastor.Nate Application forms far slaw-owned POWIS are sAtr ine4 tat Pro}trt Address(it dtf(e:em that mailing address) <br /> the Deparrrnatt of Safety arrd Professional Se-rces Personal mfotmaz aci you pro.tdr ray be used Err areccalseci <br /> o E / <br /> purposes m accatdanct with the Privacy Laws _5 CAI in),Scats c.i c <br /> f. Appiattien/*formatioe-Please Print All Informative �6�1� � ' <br /> Phvperty Otbral s NT= pa crl a <br /> 'In a-L;5 crl-c {;)-=7-61-13 SCE -I1b/Cr <br /> Gtr'�i�ri /.� <br /> Property Otter's Maik g Mons Property Location - P u i/A 3 - <br /> iva-- Cl vo-'Lane <br /> GOA t.or 5 <br /> City,Stale ( Zip Cole ' Phone Number t <br /> � Gl I _ �_ �,,..Nn h. Sermon 13 <br /> ;o, MN 6a 7St)-60(1`r T 31 t{irrct <br /> IL Type OBuilding(ekak aD OW apply) lots 6 <br /> 1s I or 2 Faimly Dwelling-Number of Bedrooms9 ��aLafd- 5rzbdrvuion Maine <br /> HMO 0 <br /> Q Pubttc)Contnucial-Describe Use €Q Cry cC <br /> yre 0 Village of <br /> 0 State Owned-Describe Use_ ro ` M-1 a te, " .. <br /> I)).'Type OP/emit: (Cheek only ens box tie kite A. Complete linr B if applicant) <br /> A Q New 5 t System Q Teststent fioldi Tank <br /> System Ttapieernsext o€' RnpLctme7t Orin ` Q Otte!laachtrestri-rro to FxisCng System(expert) <br /> 't Les Previous Permit Nti end Der Warted <br /> B. ❑Permit Renewal ❑Prima flex aim 0 Ovine of?!umber ❑PUMA Transfer to New i <br /> . Before Expiration Owner NA i IJv <br /> i.IV.Type of POWIS Sy*estiCempoaenei ,s ce; (Cierk all that apply) <br /> ❑Noa-Pressrcue:brGtouni 0 Presstrtmd In-Gr, a ❑tit.C'ra l de �;touau!?34 of of w-:-s 10:1 0}!anti<24 in at seta a gnu <br /> 0/folding Tank 0 Other Disperse:Component Ittsplain) 0 Oerxre ftxpla n <br /> V.DiepersalfTrestseent Area Imktmstiaa: <br /> j Dee Flow( nf) Design Soil /nation Ratc(e tdsI) Dispersal Area Req'' {'sr 1 Dcs.e sai Area {� System Elevation <br /> • (00 I, Li495-� Yc)s si 97' <br /> VI.Task Info Caper-ay its ' Total o of ' » r ) , - '� <br /> Gams Gas Units 'L 3 .2 <br /> y v <br /> 'Nev.Teak. Etmauig Tarim � q�+ �' laxU y it tt.L a'. <br /> 11o.:ng Chaelkar .--7 i <br /> .,,,f. , <br /> ,_ ______ <br /> VII.R sposseliity Sialeweat-I.Me wideraigsti.swot respeasibany ieeplaies of(be POM-fs stows es are snaebed phis. _..._...a. <br /> Pk' <br /> Dratoe #J Ptumba' ? 4iPtitPRS Norman Phone`;uar n <br /> cr' �t e ffi� cup �, j /03O37'-f �,,��5 C23 ? <br /> Addrsss Cry.��10��a°e�i tier ii J/f i '' t 4' �� <br /> VI1L Coeaty/Departareel Uee Only -_.__ .., <br /> �A twod Q e>, Parr::Fee 0'0 ` Oats:swell <br /> !c <br /> ell i ' g. S, <br /> — <br /> Q owner Gwen Reason fa Donut $ 375. <br /> IX.Coathtless of Apprxrva for sppro.al <br /> m e a V �� s A- 5- - :,ems <br /> , ECEIWEp <br /> A ma.Ml Our <br /> a he at a?roe.... d Mani*to Coop Caa only is p pm me tan amen a vs a II WWII. 37s;`�_v <br /> SEP 2 6 2023 <br /> iflITGI <br /> Sera+9s(K.138,,14) Burnett County <br /> Land Services Department <br />