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Saft3ti a-nd Btr7r3lrrgs I'iivisien �/N e <br /> 201 W.W;.�Ave.,r?.O.843X,7 1162 Sanitary Permit Numb"(to be filled in by <br /> 'Ifs 1 <br /> Me—ds-0.11.Wl 53707-71622 <br /> w � ! <br /> Sanitany Permit pplicattcn Sam TransacrioffNmnber <br /> in accordance ayith SPS 38_11(2),Eos.Iden,Code,submission ofihs€tam to 01 a appreprlaw s;evc�ral mtit � GO Ln.ply Wei//PU.- <br /> is required prier to oberini.•5 a sanitary g-refit hto�a fcr.�feroa PC?lY aresfursiiar`to a <br /> ppl+t� P.aject__ddress Ii€ditFerent than fmaifif>;address) <br /> the Department of Safety and Profsiotxi Se—ies_ ii�J inforr..�Arn you provide;far be used rarsecmaaav 1 <br /> purposes in accordance with tie Privacy Law-s.1 5b1t fym),Stam I <br /> 1. AnlicstionInfermation—PleasePrintAtlbdiarumfion 27399'7��° <br /> Property Owner's Name 1 _ Pace.i r <br /> Property Owers Mailine Ardr, Latatior <br /> 3Z k,, � G Z <br /> City.S;atc �L Zip Code Ptxc Number <br /> �lmr 132137 T Sec�a <br /> tL Type o€Bailding(check all that apply) � Lets , <br /> �/(�N; R�:c Eo <br /> I or 2 Famity D%vellirg-Numb:, of Bedtactts Sobel inion llama <br /> r <br /> 1 Block I <br /> 0 Publie.23mnxTcial-Describe List t City <br /> or <br /> 0 S tate Ov ned-Deescrdre Use F CSM Num°g 0 vilhae of 1, <br /> 19 AAJ <br /> V <br /> III.Tro iz ypc of Pe (C-,ec'_and ane w-Ga!--.e A cowl=c Hac;3 Wapificabu) T <br /> A. <br /> 0.\'gas$ystem C)CReptacer..ent s3rszzin T i-vmerovt iirg T--nk PeifteOrdu r Other Aiodifi;anon to Existing System(explain) <br /> B. 0 Permit Rcneaazl 0 Permit Rcvsion �t7 CSt��36� O Pertrfit Tram?few Lim PreviousPerne n Number and Date Issued <br /> Before Expiration <br /> IV. Type of PONNTS System/Component/Device: (Check aH thar ) <br /> M Nton-Pressurized ir.-Grourd Q Premriz Sn-�ratsfd 0:�Gade a lKorsrti>_2 tyre aEs irabEe h3mmd<'a�in of s±itablc soil <br /> 0 HotdinS Ta-dt 0 Odw_r Disp;f,-xl±=ampaxnt(tcplair3 Ptd.^eLt Dwica( lzin) <br /> \r. Dispersal/Treatment Area Information_ <br /> Desi an flow(g_pd) Design Sol Appticatiar:Rate( tfi) Disney sA Ana NG, Dqvrsal Area Prapas ltst} Svstem Elevation <br /> cY� 600 1 600 g2.o <br /> V1. Tank Info Capaci23•af ( Tftal 1 tea€ j it€em£anaer <br /> veHorss velhxes <br /> Neer Tanks EMTiMTangy <br /> Septic or Holding Tad: i 75 = 750 1- <br /> Dosine Chamber j 71 f <br /> h I is <br /> VII_Responsibility Stntemen t-1,the undersgaed.a t.responsibility for imtilbii0a of ahc PGV VTS shwa on the atlwcbed ptMM <br /> Plurnber1,Nt ame(Prim) ( Plan Sika+ l INU RS Number Business Phone Number <br /> Plumber's f.2-druus t5tret=.cies_st�e�L' s <br /> V11I.CountvlDe artment tis&Oa1v <br /> I Paso Feer issued Issuing �z <br /> Appfoved Disppraeed <br /> Owner Given Reatsain for Dewe <br /> Il. Conditions ofApp,-ovallRessous€orrsapprotal <br /> 1 I <br /> i r EOME ' <br /> Am,+w eoamwe alas for the s}sfi:c xa s%%bz6Zw umccounlya p hm papetgf Shss tin atr±z i t <br /> OCT 15 2015 <br /> SBD-6399 ir- !Ill l' BURNETT COUNTY <br /> ZONING <br />