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County
<br /> `fox Industry Services Division �w✓'h r'�
<br /> 1400 E Washington Ave Sortar,Pe but Nunbeclm be tilled in by Co_I
<br /> .,
<br /> ,PS . `7X1355
<br /> Madison,on,WI15 63707707-7162
<br /> Stare Transaction Number
<br /> Sanitary Permit Application
<br /> [a locadarany with SPS3S3.21(2),Ab nam CCAC,ilLbuilloarofd hour to the apprcprinre govemme,rzl unit
<br /> s mr o d p',in,to hommarga Ormular,per it Note. ,l anon forno to, late+owned PORTS arc Infrared to Project Address(t different han bodies,address)
<br /> the Depmamem of Safety and Professional Sc,,t,, Personal droned sid you Provide may be .,it gorse idi 1Yo a/e/
<br /> accordance with the Privacy Law.e.15 l,
<br /> .nulhoStnu' h S. J,6elso., 6/e /21'
<br /> 1. pplication Information-Please Print All Information
<br /> Property Cherers Name Oarcell# a- /6/b-a3 -S oS-
<br /> ��hf0. 11 I.✓arn «'I' o6S- OJ4-I GO
<br /> Pmµnty Owner's Mailing Address Pmpnry Lncmion
<br /> / 4 9J I GS-r Is ?/.f e e Al- Gnvr Let
<br /> Ciry,Stam Z,Code Plmne Number ii, Section
<br /> (circle one)
<br /> N'1a /e Gr^evr I7'1 v SS3o 9 T �/0•.N, R /G bm,r,
<br /> IkTypeof Building(check all that apply) .LmF
<br /> El 1-2 Family Dwelling-Numbetof B,dr000w -3 /�/ smuli and Name
<br /> Block a
<br /> ❑Pubin Conmrereinl-Describe Use El Cdof
<br /> CSM Number ❑ Villas of
<br /> L1 Sure Owned-D...61e Use 1C�net'.
<br /> �+y5$7 [/,zS P.4l p Town of Ot
<br /> 111*1, bay pe of Permit- (Check onone box on line A. Complete line B if applicable)
<br /> A ❑ New Sysmm �?RepImmncm System ❑ 'rremnremd lolding Tank Replacement Only ❑ Other ModiembedmExlSling Systan(,.Plain)
<br /> It. ❑ Permit Renewal [I Permit R,,men ❑Chmlge A Planum, ❑Permit Transfer to New Lin Previous Permit Numbcrand Datc Issued
<br /> Began,Expimnon Owner
<br /> W.Type of P0W j S Svsnem/(am onel1oDcviee: (Check all thin apply)
<br /> Non-I-m,am,,d In Ginned ❑ Prs..rood hi-Ground ❑ At-Glade ❑ Monnd>24 in.ofomobble soil ❑ Mound<24 inofsuimble soil
<br /> ❑ Holding Tank ❑Omer Dowd Component(esPlaial ❑Preheaarem Nvicc(explain)
<br /> V.Do ereaUfreatment Area Information:
<br /> 1)e i v I low(gpd) Design Soil Application Ratggpdsin Dispersal Area Rcquo it(,ID Dad al Area P.,b,cd(s) System Elevation
<br /> I`j , s Joe lea s5 1
<br /> VI.Tank Info Cplead,in Total Sri Muouracmocr
<br /> Gallons Gallons Unit- Lj
<br /> 1—ranks Nino,Trimn, ln
<br /> IS,,m llaldin6 reek lee /e00 / tV1eSar 'LI
<br /> rueur,(71a°'ber
<br /> \'ll.Responsibility Statement- 1.the m lorog N,assume revpomihllin fee annotation time PO\YPS shorn on the ou mai plans.
<br /> Plumber's Name(Proon Plari SiLntamre MYIMYRpS Number business Phone Number
<br /> / %/ Jd.rlQSl 7/S-cl///i' 157
<br /> Plumbers Address(Str h,Cory.Slate,Zip L om)
<br /> ,1-776,' A' 3S k1l sf 6s 7" w1 S>ss3
<br /> V111.CormIDe mr(n t Use I n
<br /> PamitFre Date Weed Issuing Agent Samoan,ro
<br /> Appved ❑ Disuppmved S ,,/
<br /> ❑ owner Given Itemon for Denial P6 Z!/'/
<br /> IX.Cundinions of Apprmml/Reasons for Disapproval
<br /> ��� �I
<br /> t_6T o l l tAna"11"'Pill'Inum rto am"arm ever:ubmnlame ennmt.omy nm piper unuef:mnexte.11 to nnma e7 U
<br /> L} BURNETT COUNTY
<br /> SBD-9398(R0313) ZONING
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