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Cnunry �J {
<br /> �!1 Safety and Buildings Division l7 ll Y(T
<br /> \S -It•rl 201 W.Washington Ave., P.O. Box 7162 Sardmry Permit Minier(tobe tilled in by Co.)
<br /> P
<br /> l St Madison,WI 53707-7162
<br /> Sanitary Pennit Application stn,Transaction wmher
<br /> In accordance wish SPS 383 L12).W is-Adm Code,submission of tM1is loan to the appmpdnte eoveminmal mil
<br /> rc ,hied prion.obtoiningasaoni,,,nnit Nam:APPlic.tion tbnm for state-own,A POWTS.rc suhmiudto projectAddress( fdiftenat that moihe,eldn,—)
<br /> the D .,a.n,nt of S.fmy end Ptnfe,nind Servies, Personal infwnaeon you provide may be used for secondary 1 '
<br /> n uccoul with the Pdvacv law.s. I5.0ni mL Stas. 302-18 V" 64r�I t17 iw+2 CK
<br /> 1. A Lcauon Information-Please Print All Information
<br /> Pe,perry Owner's Nam, I Paeel p
<br /> �J'ir o✓ SRn01'c 1.11cr� �i a. O -o31a-41-1635-SIS-poi-ol o
<br /> I'mpeay O/x ds.jailing Addrcss 1 Property Location
<br /> (� 3
<br /> 'S r14 A Ve S, Govt.Lot
<br /> City,State ZiP Cale Phone Number S 'x. seed.. aS
<br /> �fnneu Dili Mn S5ya3 IZ. 386- ylv10 lende/,y�/
<br /> II.Typcof Bwlding(cbeck all that apply) lane . TSN; R��Enr Jam/
<br /> �1 or'-Family Uwellue,-Nombcrof Baconcen aS --lT ?'la Subdivision,Naar,
<br /> Block -t f- 0J 1-D 0. n (.f
<br /> ❑PuhllerComm,mial-Describe Use
<br /> Cl City of
<br /> D State Owned-Describe Use CSM Number D Villagecd
<br /> KToonof SS
<br /> HE T}pe of Permit (Check only one baa on line A. Complete line B if applicable) al-
<br /> '\' ❑ New System Replacanent5Ystern El'rreatencoUllolding Teak Replacement Only D Oina-Modifie.eonm Eouinb Sy,en
<br /> (explain)
<br /> R. ❑ Permit Reneval D Permit Revision OCbcr,.f Phenxb, OPermitTmmfcrm New List Previous Permit Number and Dae Issued
<br /> Before Expiration Owner
<br /> I V.Tv aof POWTS S,,lem/Cam onenEDevicc Check all thata Iv
<br /> (7SNon-Pressurizalln-Ground Ol'us. ndzedlo-Greund DAt-Gnde OMound>_24in.o'suitablesoil D Mourd<23 in ofsuitable soil
<br /> O Holding Tank O Other Dispersal Companrnl(eaplaln) ❑preacitme.t Deviec(mplain)
<br /> V.Dis ersallfreatm ent Area Information:
<br /> D,,.go Flow(gpd) Design Soil Application Ret{gpdsl) Dicpcmxl Area Rv,.ioaJ( 0 Dispersal Arco Proprscdlsp System Elevation
<br /> �lS0 • .� 6 y3 3
<br /> \'1.Tank Info Capacity in 'totalpat .\lanufmmrer
<br /> Gallons Gelkne, Urdu
<br /> 1—TanW Losting Tanks `� u n
<br /> - 2 -
<br /> iUIn oni0
<br /> lvpna Iluldin6'lank
<br /> X IODO ( /Ps 'r
<br /> Ibsing Chamber
<br /> V IL ltespmisibilitv5mtement- Inhe nnd,rsiynaJ.a su responsibilitrfor insmllation.fthe YONTSshuxn on rhe mmch,d plans.
<br /> Phunber's Nonic(Pdnd Plumti -s Signature MP/MPRSNumber Be,incss Phone Numher
<br /> Ue IS Der PY �WL� ZZSLz �7S ebb- �
<br /> Plumbers Address(Street Cd,State Zip Code)
<br /> --181 4 5 co -, , 7Zd D ebs,4,,- . W S q�f9 3
<br /> VIII.County/De artmeat Ilse Only
<br /> P,nnit Fee Date Issued Issuing Agent Signamc
<br /> 11""'ed O D,,,,.old S J
<br /> D 0..,,Given Ram.fur UIcnlal 3LS 00 3 -
<br /> IS.ConditionsofApproval/Reasons for Disappro.al D E^EIra2E OCT .1 2013 D
<br /> Auah 1.oamplete pbm.I.,rbe.,oemann.uhmn m mec.......1,on wmr nm ln:manN u:.
<br /> BURNrETT COUNTY
<br /> ZONING
<br /> SBD-6398(R. 11/11)
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