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Industry Services Division -I/
<br /> fidl_OS' :., �:� 1400 E Washington Ave Saniury Permit WmM,ho be filled ex by Cah
<br /> P.O.Box 7162 Jr7 3�g
<br /> Madison,WI 53707-7162 I
<br /> ''"•'r"".'" Sin/��')�.J
<br /> Sanitary Permit Application State Inn"`°n"Nual
<br /> In aeeoaance wish }S111, n Wiz,nom.Calc,submission lose form m the uppmP W I S ar, unenwl unit
<br /> mmrylrcd poor er oM1tniningasnnimry permit NotCApplieuGonfbnuz lbrs11n6-1, POW IS orise-ted In Pmjedt AAdrers�ldlfldmm than moiling address)
<br /> in,Drr:nocol ofSaRry and rrtissional Serviee. Pecunnl infannmion you pnrviAe may be uttd Ibr,uamAary }7 s3 9
<br /> u selmorcordan<e with Ne Privac Law,s.IS MIINmI.Star. l
<br /> 1. Application Information-Please Print All Information J6+e.</ /l',,. 1, 01
<br /> PmpeM1y(Dnner's Name Pamelp
<br /> S
<br /> o2- a -d-ve-/G-d9•
<br /> dooS
<br /> ood- otSa ov
<br /> PmµnY Ow'nei s Mulling nJJrcss Pmprny Location
<br /> 8 IF/P s d /J,. (;not.Lal d
<br /> City,Sam zip Code Phone Number Jw 'L, NF 'G, S"Iniii a9
<br /> v✓i. & w Ss'/zs 6si-aze-(,eon do Rirce)
<br /> leon
<br /> 11.Tpe of Building(check all that apply) Lot p
<br /> Sri ort Fronil,Dwelling-NnmMr of Bedrmms a 3 Subdivision Name
<br /> «ktt
<br /> ❑Publi<'Cotmnercial-Describe Use �firy of
<br /> D Seta Owned-Deserihe Use CSht Number DVillageof
<br /> �t379z ti/Y Ilo.,non o</<i iso.
<br /> IIL'fype of Perm it: (Clock only one hox on liar A. Compler liar II if applicable)
<br /> A New System ❑ Hephttmem System ❑I'remmeoVl holding lupi Replaement Only ❑Other MOAifica c In Existing Svvea lexplam)
<br /> B. ❑ Permit Renewal D Psmnit Revision D Change of Pl. her D Pennit Transfer to Neu, List Previous Permit Number and Date Issued
<br /> Before Expiration Omer
<br /> IV.'I'fire of PO WI'S Svs[em/Com mnent/Device: Check all that a r lv)
<br /> yJ mon-Pa,s,on"ht-Ground D Pre,timed In.Gmnnd D ,u-Grade D Mound>24 in.of antible mil D MDuad<+4 in.ofsttiublr sou
<br /> D Ruhbng Took ❑othrr D.,x.lComponentle,pla.h ❑Prcvemmrnl Deem le,plainl
<br /> V.Dis ersalRrentment Arca Information: -
<br /> Designllow(gpcp Dui,Soil Applicmion liate"j,t) In"xuaL\rcu detested Kta Dispersal Area Proposed 1,11sysmrn Elevation
<br /> VI.'I luck Into Capaaly in Tout sof Manufacturer
<br /> Galluo Gallon Units
<br /> Vow Taub lixlstlaa Conk.
<br /> Sept¢in laid...ram / ,SO /e✓'O / ,�.� F,'/nae fe.�
<br /> wai�eEwmbzr �
<br /> VII.Responsibility Star....t- 1,the uadosigncd,assume responsibility for hnstallmion of Ice PORTS whom on the attached plans.
<br /> PIumM'n Name(Pnne Ylurnber's Saprta, hIPIMP R5 Number Business Phone NYmbscr
<br /> /?,�/' // /c, f 1 /�-,/j/j &/ self 7/s-,FA15 s 71
<br /> Phunber',Address(Shea,0,Sas,.Zip Code)
<br /> i77Go K. , 3✓r /1i-26s>'�-� w= -3`�5�3
<br /> VI IL Coeen/De artmenr Uxr On,
<br /> Approved DDlsappmviol Permit feu Uute Issued /, Issuing Agent Signature
<br /> 5 �jTi�00
<br /> ❑ Owner Given Hewson for Ucniul (G«C .Y'f<oo
<br /> IS.Canditions oL\pprm'aVReaaons for Disapproml
<br /> D Ecen
<br /> sn,mry mpPeu plan.u.r m.., m.ae,anmu turn.r.,,, .unP. �p.nr�athn m.nx n.,ton i.4✓�� 7 2014
<br /> 10
<br /> SBD-6393(RO313) BURNETT COUNTY
<br /> ZONING
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