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Caumy <br /> Safety and Balk im}s Division u( <br /> 201 W,Washinglusf Ave,P O.Box 7162 Sanimry Permit Number Im be filled in by Co.l I n <br /> p Madison,Wl 53707-7162 V <br /> S r 5 lAo9/S <br /> s N-fid-zs �- <br /> SanitaryPermitApplication Smte T.wn Namber I� <br /> In aaawderee,.'nh SPS 383 2I('-).Wet,Adm.Code,submissmn nfdris form to the apprep taa yvermnenmi wit 'h <br /> reaui2d priorm ab¢ininSa sniurr tcernil. Nott A�yli gim farms Fw.tft•i'auned POtl7S are s�Arrfinedm P.-Dicer Address lifond'-em town rtniling address) I <br /> the DCPanment of Salt`,arW Pnfessarmi <br /> the awanclare. iLev-rx15 Persmal SNot.fw¢LicationInto mation-please PrintAlinformafanvmsan Yoa Provide nay be iced fw sxcafvlary 2�6Z./J Sevel <br /> On"Oncr'S Name / Pamd <br /> qN �Q���a e)-�36�Z-yU-iy-29-3o4-opo-oIlWO <br /> Pope,Om `Mailha Address t fhoPntY La�sion <br /> 2B3S ly24e /Uw Go,Lot <br /> C/isJ. Sew zip c�d�el[/ Phana Nmnw S6- K, Sw lv., seemn� <br /> /7'aoVY I A) ��N/ �Z� �S��.IG TSN: It Eon 5�' <br /> 11.Type of Boilding(cheek all that apply) CwR <br /> I ar 3 family ITvellins-Number of Bedrooms Subdri ma tame <br /> Inner a <br /> ❑PubliclCommereled-Dessnbe Use ❑City of <br /> ❑Slate 0.ed-Dencnbe Use CSM Number ❑ Vihageof <br /> WT-..f UM-Cflj <br /> III.Ty,of Permit: (Check only one box on line A. Complem line B ifapplieable) <br /> `t' JNex'system ❑ aePiaaen'znt Sysun ❑ii®mimfMoWisg Ta�RepLxemem Duly ❑OtMr MMif Linn m fasting system(,plain) <br /> B. ❑ PermitRernwzl ❑Permit Roixion ❑CM1errSe ofPtamM ❑Pomit Tfvnfcm Nmv Lm Oaeiwvs Pena,NumMr and Dau lsred <br /> her Expim[ron O avr <br /> 11'.1%peof PO1VTS Svscem/Com oncnWtv'me: (Check all thatapply) <br /> on-Pressuristlln-Gmw4 ❑R¢nviowln onwrtl ❑AIGrede ❑MowW?26 in.ofsr2-0Ie wJ ❑MouM<>_glnar,oa.blesoil <br /> Ll <br /> ,I a. <br /> TanA ❑Other Dispaw Compowat(expWn) ❑Pran"doent Deviee(elho") <br /> V. Dis ersa lffrcatment Area Idformatian: <br /> Dexian fin" pd) Desien Soil Applienion Rwdgpdx0 IN owalArea RryuInal f) D' IAaw Pmpmed pyi 5}ztem0aeutan <br /> y,6 /9Z yZ 9Z.v <br /> AT Tank lnro Capai.w. Total paf AlerufacMcr <br /> Gellnm Gallas units = - _ _ <br /> hw'TaN Fuaap Tmas - �+ _ <br /> cJ - ➢ 0 <br /> S,,e, r.ww,TmA v <br /> Don'Clamber <br /> VII.Respareobiltfy Storeman r-1.the ond—igneL axsome reyunmidtr For ioonlhdwl er the PON'R%boon ne the atbebed Pbn <br /> Plun is Name(Pring Plum MP/ SNmnber Business Phone Number <br /> s o 7/3 66 7b <br /> Plumber's Addres(ffieeL Gty,Smre.T.ipC�s1 <br /> 272Zo � f � Ku (Ne�S��w:54E3g <br /> 1911.Coon MDm <br /> e aftent Use Ooh' _ <br /> Approved 0Dixapprwv3 Permit Fee Dwe ISN L¢umg Agan SI! <br /> ❑D..ner c.en Roawn rw Denial <br /> k 3zSc< f!!f iy <br /> IS.CnnJitions of ApprovuVReaeons for Dfmpproval V <br /> _4114 <br /> nn%.l meomntm mwo.mr un.nnm>va mbwtm�xcaaen®n oo papefanrl _atn.D mrw m:ta <br /> BURNETT COUNTY <br /> SBD-6399 M 11/111 ZONING <br />