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.6"'Rvr County <br /> Safety and Buildings Division / <br /> (n . ,� 201 W.Wastmlgton Ave.,P.O.Box 7162 5aniury Permit Number no b,filled in by Co.) <br /> �'U'S;. • Mai WI 53707-7162 <br /> P <br /> nion N <br /> Taher <br /> e r um <br /> Sanitary Permit Application SwP <br /> In acmrdame xilh SF531321(2),W¢.Adm.Code,svdniaion of N¢fam rthe vpPopriae�vumnmN unit l'L<UI <br /> r<g,,va , tosafetyia , rosecvpermit. Nae: informal <br /> may <br /> bi mdFoAmitdr Pmfeel AddreslirdiR rem tbm�mailir�gmaressl <br /> the Dcparmrcnl of safety artl Natesstotai Scrvies. PersorN mfamatlon a'ou Wwide rrmy b and f secoldary / <br /> accordars<:orn the Priv Iaw.s.15 010m SMIN. 06 �•/YA <br /> 1. A Heittioninr., rum —Please ran" lnformLinv <br /> Properry oxx a',Name Pareel a o7-ap t-40+'SM•3 o3-tto'a/ao <br /> a/,j 01A 3-00X0 <br /> Property Ossner,Mailing Address - property I.oeuion <br /> Goon Ln1_ <br /> Cin.51' 61,1 /�l LwG yz 61ZNZz�- ( .t/ v._sr l v,�.((55s$se�<nion <br /> T NO N; R L5 I[or� <br /> ILT}pe of Building(check all that apply) � Lmtl <br /> 1 or 2 Family Dssellirig-Nuentor ofB<dmoms Subdivision Name <br /> Block 9 <br /> ❑Public/Commercial-Desexibe Use City of <br /> ❑State Owmd-Diatribe U. CSM Nw�ba ❑ VillageoF <br /> Toot ilcklel/l/ <br /> Ill.'fype of Permit (Check only one boa on line A. Complete line B if...licable) <br /> A. cfNe-s'slem O Repla,emnu Syaeia OTank Replaevnm DtdY ❑Otic Mdifi®tion w Fisting 5ycrem(explain) <br /> B. O permit Rarcxal ❑ permit Revision O Change of Plumber O pemit Trans(m New Li t Prcvvaa Permit Number and Dal,Issued <br /> Before Expiration Osuer <br /> IV.Tv c of PO\\'yS Svstem/Com onent/Devlee: Check all that apply) <br /> •4 Non-Pressuared lrs('xwd Dprealanxi In-Grund DAI-Gmde D MopmL?21 in.ofadabksoil DMound<241 in ofwirble an <br /> 01lolding Tank DObm Dispersal Com,xx,m xplainl OPrVcahnent Devi¢(expl.ce) <br /> S'.Dis ere.Vfreafinenl Area Information: <br /> Design Flow(gptl) Da ran soil "rear Rm(,pd,n Dispersal Area Recarmal(d) Material Arra Pralareed(,0 Syz <br /> pp ' y2 �j 3 V1.Tank Info Capacity in Trzl SofGallas Callan um. _New Too, Fomaim,Tmb - j p'UuU <br /> on <br /> sex—HaWmFTaM; <br /> Dmina CTmiEc 1 LKJ LtV <br /> \'11.Respomibilip'Stateroom 1- 1,the exdrrdgoed,assomrms(rvdbility for installation of the pt)m Bdnwn on the mched ptanv <br /> Plu is Name tPrinl) Plumber' . MP/MPR$Number Ba,,.Phare Number <br /> a l�a P! 5j95�/ 7/b 70 <br /> Plumbm's Address fS city,star,zip cq�) <br /> Z7ZZa �;' Kcl <br /> VI 11.Counp'/De atment Use Onb' <br /> Apl.ovd ❑❑ cd SwI Fe Due/F'Farad romance <br /> oxvrvenRwfrD<nw C�5 <br /> IN.Conditions of A,proxoVR.,orox far Disapproval M(� <br /> Sec .tail APP12u.v( /-e.({Fr f4'�Y.1w�. D EC��1J kLn <br /> Amrn r<ommeur olan.r.uMx=o-m axdax.itr m<eoutr mtr+noowtn.leanem TMO 6 LU 13 <br /> SBD-6398(R. 1 Ill l) BURNETT COUNTY <br /> ZONING <br />