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i di+eei�w 'odds <br /> / us Industry Services Division <br /> S r� 1400 E Washington Ave similar,Per//m�,it Number(to be filled in by Co.) <br /> 31, P.O. Box 7162 SIr✓fo 9 t0 <br /> .s em�`� � ref Madison,WI 53707-7162 3 <br /> �"'�ileS MI/ <br /> Sanitary Permit Application Sam Tmnsxdon Nmnber <br /> In accordance wind SPS 383.21(2).Wis.Adm.Code,submission of this form to the appropriate goveradvatal unit <br /> israluvedpriortoobtawwgasauimry PermitNote:Applicazionfodms for sbtrownN POWTS are submitted to Project Address(ifiiR nt than mulwg address) <br /> the Deportment of Safely and Pmfnsional Sereic, Personal wf der ation you provide may be usr f r secondary <br /> purposes <br /> ccmmd <br /> dce with the Pnvac Taw,a.15.04 I m),Slats. SAn'lC <br /> f Application Information-Please Print All Information <br /> Pmpeny Owner's Name Parcel0 <br /> 07 OA O A VO/b 33 SOS 04 <br /> 1 ccjn es, c,Veee <br /> Property Owner's Mailing Address Property Location <br /> 7,v6 s. D<Vils 116'ed Gnvt l.nt <br /> City,Spite Zip Code Phone Number <br /> S, &, Section 33 <br /> tV6b.5fer u,L 5-'f893 (rheleone) <br /> H.Type of Building(check all that apply) 11 Lot q T�Q_N; <br /> ® I ort Family Dwelling-Namberof Bedmodre P '7 7 Subdivision Name <br /> Block d <br /> Public/Commemiai-D[senbe Use <br /> ❑ City of <br /> ❑Mate Owned-Describe Uu CSM Number 11 Village of <br /> !// azle/ Brown of . oca7�..d <br /> III.Type of Permit: (Check only one box on line A. Complete line B it applicable) <br /> A. L1 New System RepL¢emen[Sysrem ❑TrcamoduHolding Tarr Replacement Only ❑ Other Modifiwtiou to Existing System(explain) <br /> B. 11 permit Renewal ❑ PermV Revision ❑Change of Vlumber ❑Permit Transfer to New List Previous Pereit Namberinl Date issued <br /> BureEstrada. owner a983y �fp'i3-/98/) <br /> IV.Type of PO"'SS atcm/Com o ent/Device Cheek all that apply) <br /> ❑ Nov-Pressurized M-Ground ❑ Presmrb.M InGrmumd ❑ ekt-Grade ❑Mound>24 m.of enable soil ❑Mound a 24 in,inaudible soil <br /> R Holding Tank ❑Of u,Dnpasei Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis e,sid/T.tment Area Information- <br /> Design Flow base) <br /> nformation:DesignFlowbase) Deaigv Said Application Ratob alit) Dispersal Ana Required(so Dispersal Area ProP.nsed(st) System6levafiot <br /> VI.'fanklnfo Capacity in J 'Total etof Manufacturer <br /> Gallons Gallon Units S o <br /> re,Tanks Faisting Tanks c - q <br /> c xi <br /> sepdm m1 xnmimg Tank d.feo p(,Spp <br /> Wsimgchamber <br /> V Il.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's Simulate MP/MFRS Number -u up" <br /> Phone Number <br /> Ree(e ye 7,[5- 8GL-His7 <br /> Plumber's Address(Stec CCity.Slate,Zip Coda) <br /> 7760 3S we-Ari. S�1"3 <br /> VIII.Coundy/Deltartiment Use Onl <br /> APP[oved ❑ DisaPPmved Permit Fee flat Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Taoist <br /> IX.Conditions of Approval/Reasons for Disapproval O� /moi ��c-1 III�Ih1I�II <br /> IIIALLrrr�'..JJrrrL„I11\\111 ,•rJJ--' II�fLJJn V <br /> JUN -, 3 2014 <br /> Montano mmplele pleusror llde ryilem and rvbmil to the Cmuely mly oe paper oat lea then 0lie[ha to slu <br /> BURNETT COUNTY <br /> SBD-6398(100313) ZONING <br />