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�r•mrse County <br /> Industry Services Division Burned <br /> 1400 E Washington Ave <br /> $In P.O.Box 7162 Sury P <br /> narermit Number Ito be filledin by Co,) <br /> S Madison,WI 53707-7162 <br /> 'wry w�T 5-7737z <br /> Sanitary Permit Application Stan, ItwaationNumber <br /> No <br /> Inestated pe..w SPS383.21(2), e,,Adm.Cala,submision ofNisf to the gpnpnatc gavemmwul it <br /> is [X7md prior to ubficty ng a swhary partner es. emmWtinf mat for pmvived ay W u vire submitted te <br /> the lhywnaccof Saferywd Aof sinnalservi«s. Personal information yon DroviJc may be uuJ fur uamJary Pmlacl Aasour ([AeImit than mailing aJJrcss) <br /> u in accadarce wiN the Pnvacv law,s. 15.01 I m,Sues. 29310 I lanswm lake"I milxay <br /> 1. Application Information-Please Print All Information <br /> Pnperty(Tmtt's Name Parcel a <br /> Daniel and Rachael Dols 07-028-240-144 505-003-b2— <br /> Property Comer's Mailing Address properly laridion <br /> 3385 Griggs Sr Nash <br /> G.A.Un 3 <br /> City,Swe7,ip Cock phone Number '/., V.., Section 6 <br /> Prior lake,MN 55372 Jt:udewe) <br /> 1'408 R14 Eo W/ <br /> 11.Type of Building(check all thatapply) I+n# <br /> ED I m2FamIy Dwelling-Numbcrofl4d.x 2 Subdivisilm Name <br /> Na <br /> ❑Pubbr/Cammercial-ttsenbe Use B1mek a <br /> No El City of <br /> ❑State(hvncJ-Ikscnbe Use <br /> CSM NumM El village of <br /> Vat Pg.33 in.of Senn <br /> III.Type of Permit: 1Check only one box on line A. Complete line B ifa licable <br /> A. ❑ New System ® RaI..t System ❑ Trearremullnlding Turk Repliventnt Only ❑ (nhtt MWiGcatiun to Existing System <br /> (explain) <br /> g. ❑ permit Rwewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Numhcr and Dam Issued <br /> Before Imorminn Plumber (Tuner <br /> ovsoz 7-zv-/s7s <br /> IV.Type of POWTS S stem/Com nent/Device: (Check all that apply) <br /> ® Non-Pressuoi dIn-Gmund ❑ I4nsuriecd fin-Gmund ❑ AHimde ❑ Mound>24 inofmitable suit ❑ Moumd<24 in.of..sdattlesoil <br /> ❑ holding T.k ❑Other Dispersal Componwl(explain) ❑pretreatment Dcvioe(explain) <br /> V.Dis emal/freatmenl Area Information: <br /> 0.ign Dow(bpd) Design Sal Application Dispersal Area Rcgared(s0 Dispersal Arta Proposed(s) System Messina <br /> 300 Ratc(gpdsf) 429 Evtiuf4 O C-I=W.ITG2=92.50' <br /> 7 <br /> VI.Tank Into Ceasity in <br /> Gallons <br /> Taal 4 of <br /> Nw Tants Eset-a TbGeluns Ilnits Mwuhcwar ' re <br /> N 3 = a n <br /> iu° u a <br /> Septic or Holding Tank 800 8001' I Iu11'cutt Concrete ® ❑ ❑ I ❑ I ❑ <br /> Dosing Chamber I ❑ ❑ ❑ 1 ❑ 1 ❑ <br /> VI I. Responsibility Stalemenl- I,the undersigned,assume responability for installation of(be POWTS shemn on the attached plan <br /> PlumMr's Name,(point) I'ltmdrrs Si'wme MP/MPRti NumM Bmmess Pham Number <br /> Luke Schmib. �� �( 8114121 715-0fiN2434 <br /> Plummer's Address(Strcq City.Stat,Zip Cale) <br /> P.O.Box 160 Shell lake WI 54871 <br /> Vlll.Count /De artment Ilse%Appsmved ❑ DisappmveJ PermilF¢ Wte Lsued Issuing Agent Signmum <br /> ❑ Ovmerriven Reawm for Denial 1 $ <br /> IX.Conditions of Approval/Reasons for Disapproval _ <br /> -wra � f 6� a�nr�oned 4 i ,� /� 1 IFF I vV'� <br /> /I+/ssh wkeef nr,:,. st,{/xk/G Fet a, p gp.Hy/,ie 1 _J�, V �1 <br /> (";ii/lbseefa-v ted J{ /a, aAwti,10~/heCweI47 ![)� mr <br /> Allvab ry rnmpW p6m for nae eplem avtl xvbmir m the Cauvry oery on pryer van let roto B In Ni l iitoos in ane <br /> JLBURNETT COUNTY <br /> ZONING <br />