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County <br /> w Industry Services Division Burman <br /> g 1400 E Washington Ave <br /> P.O. Box 7162 Sa4Z Permit Nuber lm be filled in by Co.) <br /> �.' Madison,WI 53707-7162 /t4 <br /> '4�Oj+wmanxe� <br /> Sanitary Permit Application Sum <br /> e Tormosttion Nomber <br /> N. <br /> !s=" <br /> n ocwrdance with SYS 393 21(2),Wit,Adm CWe,submission of this fm m the appropriote gmammenul unit <br /> is m4uited prior to obtaining a sanitary orniL Note:Application f fm atsm w PO WTS ane submiuW to <br /> the 1)epw t of,Wcty and profesimml S iea_ Perwtml mf ation you pmt'ide may be mW fm seenndary P jq Addr (if diff rot than mailmg oddrat) <br /> u >sa in scordance with Ne Priv Isw,s. 15.04 I m,Srazs. 1170 Roberts Rd. <br /> 1. Application Information-please,Print All Information <br /> property Owner's N. Pawl# <br /> DanielJ.Bmdm 07-028-2A0-14-24-5 05484-023000 <br /> Properly Owner's Mailing Address property i-,s amo <br /> 1544 Cn.King Coon <br /> G.vt.Lot 4,5 <br /> City.Sure '7.ip Cook Phone Number i 'A, Section 24 <br /> G..,IL 61254 (pfde arc) <br /> 'f 40N R1417a <br /> H.Type of Buildiog(eheak all that apply) 3 2 1,m## <br /> ® mP <br /> I2anily DwellingBcdnerm <br /> -Numberof22 UmttxxOsd Plat Subdivision Nae, <br /> ❑PubliW..macial-I fibs Use Block# <br /> City <br /> El Sum Oxmed-Ihzcribe Um ❑ <br /> CSM Number ❑ Villagege of <br /> No ®Town of San <br /> III.Type of Permit: Check onl one box on line A. Complete line B ifs liable <br /> A. ❑New System ® RWlacement Syron ❑Tratmentd lolding Tack Replaaanent Only ®Clhor MWiftation to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Pill fmmf r to New List Pmviam Peonit Number ad Dole,Issued <br /> Before PxPiraion Plumber Owrer <br /> IV.Type of POWTS S stem/Com nent/Device: ChLTk all that apply) <br /> ® Non-P exeorin:d I.-Grmmd ❑ pr mood I mand ❑Att mdc ❑ Mounts!>24 in.ofsoimble soil ❑ Momal<24 in ofmitable sail <br /> ❑ Ilolding Tank 00ther Dispersal Compooem(esplain) ❑Pteuamnent Devi.(explin) <br /> V.DispereaVYnotment Area Information: <br /> Design plow(gpd) Design Soil Appliatim Dispersal Area Required(s) Dispersal Area Proposed(sn System Elmaion <br /> 450 Ratggpdsn 643 EISA of660 C-1=9540'C-2=95.00' <br /> 7 C-3=94.50' <br /> VI.Tank Info Capacity in <br /> Gallonsof E <br /> New Tads [uaiag Turks <br /> Gallons Un is Malufanmm a U u vs, glJ 6 <br /> Septic m Holding Tank IWO 1000 1 IluRcuRConcma, <br /> Dosing Cbmnber 600 600 Combination ❑ <br /> VII.Responsibility Statement- [,Me undersgned,assume responsibility for installation of Me PON'IS shown on the attached piano <br /> Plumber's Name(Print) Plumber's 'gn MP/MPRS Number Bminest Phone Number <br /> Luk.SchmiV. 884121 715-068-2434 <br /> Pmaba' AddressStara Lip Cod ) <br /> PO.Ba. 160 Shelf IAe Wl54871 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved permit Dae I..w laving Agent Signal. <br /> ❑ C3me,GivanReason r Denial I s 7izS.00 S-iJ /y <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Gsr-a/-Sy ���� JUL 2 8 20 <br /> Arorh to complete pons for Besensor.W svbma to me Coomry only ox vapor rt be urn a to a t t I i.9s <br /> BURNETT COUNTY <br /> ZONING <br />