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sa"ara'ra> - Coumy b <br /> ��.',�*e,, � Safety and Buildings Division u <br /> LO f 201 W.Washington Ave.,P.O. Box 7162 Sanitary permit Numbc(to be filled in by Co.) <br /> =f_P,°S Madison,WI 53707-7162 <br /> 6IN310 <br /> Sanitary Permit Application Stick Transaction Number <br /> to accnrd®ce with SPB 3g121(2).Reis.Adm.Cod,submission of this form in the approrate,gmanaeremal mut <br /> is required Prior to obtaining a sanitary permit Notc:Applicatiorfotms far mateowned PDIVTS arc submitted b Preject Address(if diffnent than mailing address) <br /> the Department of Safety and Rofmional Setvia. Personal infonmtion you provide may be used for secondary /D p� �,/ /� N4.� Y8. <br /> purposes in accordance with the Pri Inv s. 15. I m Slab. I l-Ql- <br /> I. Application Information-Please Print All Information <br /> Property Uwer's Name /1 Parcel NQ7_ - .. 7-( - *' <br /> J'eA/ecq. i"An a7 Geri✓ 40 --ouJ - Ol/00/ <br /> Ropttryw <br /> Oner's Make,Address // �/ Property location <br /> / <br /> / / O 3r' tz.Ar(YQ a au' /C�j(] Govl.Lot f . <br /> Cili/ty,State +' ZiP Code Phone Number �/. y, section �1 a/ <br /> 1 3-7 N: R (circle <br /> 11.Type of Building(check all that apply) I. # <br /> I or 2 Family Dwelling-Number of Hadmoms Subdivision Name <br /> Block f <br /> U publir/Commefcial-Describe Use <br /> ❑City of <br /> ❑Stare timed-Describe Use CSM Number U Village of / <br /> Town o[ t/-asd� �WW�t� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. U Ni System Rrylrammt S stem U TrwMrnVHoli ing Tardc <br /> > Rcplacemcm Only ❑Other Modifirntion to Existing System(whim) <br /> B. U Permit Renewal U Permit Revision U Change oftalumba U PvmitTmsfer to New Lim Previous Pemut Number and Dote Issued <br /> Before Expimti® Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that n 1 <br /> ❑NonRssurisd"court ❑Pr¢mrisd B-0tmmd U AtGmAc U Mom,d>24 m.ofsuimilc soil U Mound<24 in.ofsuiubk soil <br /> Holding Trials ' U Other Dispersal Component(mpla r) U Retrminent Dcviee("Plain) <br /> V.Dis ersaVl'rca ritArealnfu-notimt: <br /> Design Flow(gpd) Design Soil Application Re[c(Wdsl) Uispvsal Asm Rtyuired(s0 Disposal Area Proposed(50 Systc Elevation <br /> VI.Tanklnfo Capacity in Total Nof Manufacturer <br /> Gallo. Gallom Units <br /> New Tacks homes Teaks m U - s <br /> cu E i U a <br /> heretic m Holdout Tara <br /> c0 N� <br /> Dosin6 C'M1mbw <br /> VII.Responsibility Statement- Lthe undersigned,assume responsibili for installation of the PORTS shown oo the attached plans. <br /> P/l^unn5 <br /> c1T's Name(Print) L Plum r igna MP/MPRS.N�xumber Business Phone Number <br /> �retcYt+rZrC <br /> Plunder's drss e (Street,City,Stare,Zip Code) <br /> s\'yIII.Count'/Dc arlment Use Only <br /> qu Approved ❑DisaPPmvcd <br /> Recruit fee Daze Issued Issuing Agent Signmum <br /> S <br /> ❑lTmtt Given Rwon for Denial <br /> UC.Conditions of Approval/Rnsons for Disapproval <br /> /has'( /nEET FGouDPGiI/ti ,2�GULA77nA5 FoK 9ii Au6SS� D ECE ll E <br /> AlIr 1 9. M14 <br /> Attach mmmpleh plate rorrhes,cm ondsubmilto the Cuunryonlyon papernat less than A in z 11 Uhtnaa, <br /> BURNETT COUNTY <br /> ZONING <br /> I . <br />