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Safety and Buildings Division County <br /> ` 201W.Washington Arc,P.O.Be,7162 w� j e <br /> isconsin Mmlisoq WI 53707-7162 SenSry Perm Snomr,ne ba filled in by Ca) <br /> Department of Commerce (609)2643151 <br /> Sanitary Permit Application Slate Plan ID Number <br /> InawomxANeomm833l,Wo Adm.CWe,paowlinforma...nyou Provide a <br /> may be mon for secondary purposes Privaev fav,s19.W(Ipm) Project AdJras(fmilcrent Ilan mailing address) <br /> I. Application Information-Please Print All Information fY— / 3 / / <br /> Property Owner's Name ` fY preterit <br /> oe S I�4#6 } 17-1Wp <br /> Proiter� ailngAddress <br /> cil <br /> p I'roprr'taadon <br /> 03S A� y <br /> City,Surf I y / Q Zip Carley Phone Norther ��`/'/.,� /., Satian� <br /> ma <br /> T3O N: It <br /> II.Type of Building(ehack all that apply) <br /> i-ar2Pamity Ux<Iling-Numbcrof Bednroms Subdivision Name CSM Number <br /> D Public/Commercial-Describer Ilse <br /> ❑Sute(Tsvw-0.vrmc Use ❑Ci D�'t,'4 .m,hiPof <br /> 111.Type of Pcrmil: (Check <br /> ,,,�lll or l) one box on live A. Complete line It if applicable) �����s <br /> A. DNe,System cPlacemem S,na. ❑TreatmenUBoliing Trunk Replacement Only ElONa MWifcation to Brisling System <br /> R. ❑ Pmmh Renewal El commit Renion ❑Chungeof ❑Permit l'ramilow New Llst Previous central Nmnber and Date I...W <br /> Befo¢Gapimtion I'lumber Owner <br /> IV.I's'seofPO\VTSSvstnm: Cbeckallthatas IL <br /> ❑Non-Prv.mirW ln-Ground ❑hotrod 124 inof on.ble soil Mound 124 indamnable it 11 A,Grede ❑Single Pass SaW Filler D <br /> Cmtatrumvd Welland ❑ 11,vi uv iacd ImGmnnJ ❑ IIalJing'fank ❑Pral Fi11w ❑Aembic'1}ealmenl Ur,t ❑ftccirwluling Sand Piller ❑ <br /> Recirculating Synthetic Media Filler DLrachin Chamber ❑Ori Line ❑(ousel-less Pip ❑Olhero,lamo <br /> V. Dispersalirfrealment Area Information: <br /> Uesign flow(gpd) Uesign Soil Application Rme(gpdit) Di, -oal Area Rcauined(sl) Disparol Areo Proposd on) Syslam Elevation <br /> vsv / -7 o ysd 9,y-s/ <br /> vi. rank Info Capacity in 9'mal Number Mnnufacwrer Prdhb Sim SIM Fiber Pla tip <br /> Gallons Gallons .1'Unna Concrete Consomcwd Glass <br /> oyes Euu;np <br /> r..tlr r.�ss <br /> seWowtaaa:asynk / (� �QU(J <br /> Aacbw Trianere unit _ <br /> Dasiny Chsmber Q.\ i <br /> %'11.Responsibility Statement- L the undervigned,assume responsibility for inslallalmir of the PO W I'S shown an the at ached plan, <br /> P1 e' Na e(Prl�9yy Plumber's Signaure MP/MPRS Numhr Business Phone Number <br /> Me- � 4r�11141 GJ �z769/ �Y9 7z�6 <br /> mmber's Address(sveq City.Seta Zip code) <br /> VIII.cmon n/De anmrnt Use flak <br /> AppmvW ❑DivpprovW Saniur'I'amn Fee(includes(immldxaer Dale lssuW Issuing Agent Signature(No Stamm) <br /> surcharge I'm) <br /> ❑oxnerGiven Retmnfor Donal * 37 S.oC., 9-3o-I <br /> I.C.Conditions ofApproral/Reasunn for Dbappnnnl <br /> 5}al'c Aps/rouu.( <br /> TrAws. Zp..a2ia1768 <br /> RDSt4e Ln \iuvM1 mmVleo-Plvm Uu tAe C _ EyE <br /> OVE <br /> nSEP 3 0 <br /> ou n <br /> vmaae <br /> BURNETPCOUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />