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- - &a 201 W.WasbnOm Ava <br /> In WI wilb Comm 8321,WiL Ada. Code PO Box 7302 <br /> See»side for nsumum for complete dais app6catioe Madison,WI 53707-7302 <br /> isco�in Phisoaal b&m+im ym PmrMc may be and fm seoaadmY Puqmu (sem cepicand rarm to oomty if ant �D <br /> Deparbumd of Commerce tprivacy 1.aw,s.15.01(Ixm)) soft owned.) <br /> Attr3 aoaplele P�(to fla aomty coP7'07171) s7mem,O I PRa'am 8-112:119m2m a sine. f n <br /> faavbsta appGdoa S1re1!IaeLDAlimbrr <br /> comayA. <br /> I Dlvlo(oB.Z <br /> L kktios Iu%nuMm-Y'kaae Prlat m Ltorai d= I.ocaaioa: <br /> c' c �p l.s <br /> lAtNwwba mom <br /> f:`/1 v �e�'Sc)/� /�h IWl Wl/4,SJ�T_]o N,R E a) <br /> Z Z `l2 ,Z 6A,,S6 n C or <br /> u city <br /> Type of Bmileia�: (dace.nae) 3 o vvabae <br /> ❑ 1 or 2 Family Dweltio8-No.afBertaeats: gle m of <br /> ❑PablidCommaod(ddaBe asex_ La <br /> 17 Slate-owned NUM"Read <br /> TEE <br /> III.Typo of ljb(Check only as boa an lime A. Chectbmk on line B if applicable) m <br /> 2 Replaeea�eal 3. of 4. <br /> A) 1. New 5' Eads m System <br /> SYstem Sygm Tmt oely D.te bored <br /> B) ❑A Sanitary Pcm[was Pmvi0uY ironed <br /> IV.Type of POWY Sysbm:(Check all that apply) WMomd ❑Sand FaE11w ❑Coamncied Wetland <br /> ❑Prcuorized to gourd [I lioldu6 Teat ❑ShI Pas ❑Drip Linc <br /> ❑At-gkade <br /> 13 Aerobic Treatment Usk ElR ❑Mer <br /> V.Dispermv][reatmeat Area InformxtbwRare Slmm F]esa6oa 7.Final <br /> 1. PamR J� 4-&A ARIUM16001 Nazi iii Raar(GaII /s9-S) <br /> VII.Tank Capacity in Total /of a Webb Sito- Steel Fber- Ph�stic <br /> Iafotr.atioeGAM Gallons Tacks Con- Con- <br /> orae anumd glens <br /> Near <br /> Tanks Teets ❑ ❑ ❑et <br /> ❑ <br /> O ❑ ❑ ❑ ❑ <br /> 6on) <br /> V,Respty Slatemtat <br /> a:su ac for iasfaQatioe dAe P07VTS spawn m Ae amehad phot I�ubtr <br /> m� <br /> [tPhm4*eftAAdr= ," u1 /3�65� ��S 6S3 ` 2505 <br /> 36�Z,I/S/A s t `�- <br /> DL CmutyAa Erbmaa t Use 0114 <br /> Pec 13U Wed <br /> D.� ) <br /> gWApproved ❑ownerGina mitisl Adverse s ) 10Dderamiamlillift' 4 \V-/ <br /> tet/ <br /> X e7o aitioas of Approval/Remo 1 for Dlaapp <br /> LQ <br /> OCT 1 9 2004 <br /> BURNETT COUNTY <br />