|
/ `rr �, Comm,//
<br /> f -. sQ.. Industry Services Division L'JCf//9P
<br /> 0 1, 1400 E Washington Ave Smara,Permit Somber(tobl filledin bCal
<br /> .k \S P 5.' lar P.O. Boz 7162
<br /> r ,IN Morison,W153707-7162 56688y
<br /> Sanitary Permit Application Sate Tmnuchon Number d
<br /> In acwNance xith SIS3El21(2),Wis.Adm_CWe,sulunissionofthisfrommtheamiol iegovm enul unit
<br /> is requimdpriorW ohuininyasalary panni). Not, Appl)moonl'oanslia,um-owntl POWISimemleined ,, in,raAddne,(it deli tlan mulling addreul /1
<br /> the wrynrr tit of Safer'and Prnksmamll Ser e, I'enl mrwmno -ou Inn.ide rosy he usd nr-indary
<br /> ntdnn with the rrlvacY l.a camlsa 1 m) Sa6_
<br /> lu A ssdiralion Information-Plra,e Prim All Informaton
<br /> Properly Ownar's Name P' reelk dsm a
<br /> G/eon ,� C/ti.S{i„ e � /r OTG/y-,1 :d /5-nvsa�
<br /> Iho WtY pxncr's Mailing Addrsms Pnquty I uwtion
<br /> a Gavt Lot _
<br /> On.State zip Code Poore Namher V, , Seeuan
<br /> Ace �/lL � 5elg6F
<br /> IL'I'y Pc of Building(check all that apply) lauN v
<br /> PU I or 2 Family Uxelling-Number of ltedion. / /q Subdivision Name
<br /> Block k
<br /> D Public/Commercial-Dcv i.be,Dsc D Cin of
<br /> D Snim Oxncd-Duscri he Use CSM Numter ❑ Village of
<br /> Tnwn of Z� //c' �e
<br /> Ill.'I,pe of Permit: (Cheek ont),time has an line A. Complete line I4 if applicable) Q
<br /> A. ❑ New System al�Yn 19'emomtl✓�YTank Replamment Only ❑Other Modifi,eimn,,Existing s,Mem(explain)
<br /> R. ❑Permit lomxal DPermit Re,oian ❑Chan O'lumber ❑Pctmh to Nex Lul Previous lbrmit NnmMr and Oac Ls�md
<br /> nrfarc t pimuull Oxncr Trvns@r
<br /> IN'. Is pe of POWI S S,stem/Cum onenkfDc%ice: Check all that a h-
<br /> BNon-MessurieNln-Ground' DI'reaurieNla-Ground ❑Abfrede C Memnd 124 inofsonable soil C Mnund,24 in.ofsauMemil
<br /> C Holding Tank D Other Dlsper,t Component(explain) DPretnumnentE ico(explam)
<br /> V.Dis amaV1'rcatment,traa Information:
<br /> Ihsign flaw(glall Ocsign Soil Appliwlum R,1e(,p&O Ois,rsal Arm R,aired(,0 Ilispersul Area lhapouW On Syncm Elemtion
<br /> VI.'I'unit Info calurlt. n 'foul 4 o Maml,rum”,
<br /> GullonsGallons ))nits --g _
<br /> ScpdawHoldu�p l'ah 1 / [CF LG
<br /> D-itClamhe,
<br /> VII,Responsibility 1.the undenhnee.- m,mponelbilip forinstamton niche 1101VINshown on the alowlimel plarox
<br /> PlmnM�r/sNme(Prim] plums',Slbnawre �— MP'MPRS Number Ifus ness Phone Number
<br /> Plumlcr's Address ISaml.Ciba,Sate,/.iP CtMe)
<br /> o /GG � Lade- C�s/f,S'7
<br /> VIII.C..."Mr forem Ilse llnls
<br /> Pamir Pec Date Iszmd Issuing Agent Signature
<br /> Appo,cd C O,,m,r oo 5 s
<br /> ❑oxner Given Roomn Ra Denial 3Z,T.00 //'/3'/3
<br /> I\.Conllitians of Appro,a UReasons far Dirapprmal
<br /> $cl7 'fro, o35o-,,;,l ,'s At, ek,14 fi lNk'ea44-4- sal%s arw<^' eK. /u✓
<br /> Q ECEVE nn
<br /> .Much n.romNrn Plam roc m.,.,am,m,.haa�md.roan.tip on pa R.wrlea n,axm t nMJ,rr 7 7013
<br /> Sil D-639g(80313) BURNETT COUNTY
<br /> ZONING
<br />
|