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Coo
<br /> Safety and But
<br /> Division BURNETT
<br /> rDS 201 W.Washington Ave., P_0Cox 7162 S Iq F ..lerola ho he e0cd m ay Co.)
<br /> F Madison, WI 53707-7162
<br /> s
<br /> Sanitary Permit Application
<br /> uuv-/u- 9
<br /> In accordance with SYS 383.21(2),Wis. Adm. Cade,nhnuoimi of Ihis form to the appmpdate govemmemaI
<br /> timl IN rcqulr i prior to obtaining a sanin,, irerant, Note: Apphcauon loans n' 'late 1—ned PONVI S are Prolem Address pfd.fC-,T, Its,,mailing add-1)
<br /> submined to the Depanmgn ad Safer, and N essinml Sen9n. Personal inforrina .on po—de may be mW 27209 JAMISON ROAD
<br /> fnr,uondaty pulmses h, rocomance I. the Pdva, law,e. 15.04(l)(nny stat,.
<br /> AlEBSTER, WI 54893
<br /> I. nldiratinn 111.1 nation-Plessse Print All Information
<br /> Property Owner's Nmne _ Parc)p ---
<br /> BRIAN 6 BETH LORENCE 07-020-2-40-16-31-505-004-c,s,,
<br /> 'mpeny Owners Mailitg Address - Pmlxm lacmmm
<br /> 1056 114TH ST W un"_ fot--A—
<br /> Ci SISam ZIP Calc Phone Number V., y,, Senuam
<br /> INVER GROVE HEIGHTS,-HN 55076 N/A (arae one)
<br /> T—kD—N: R IF For
<br /> II. T)7n'of Building(check all thvl apph') Lm k
<br /> ed or 2 Family Dw,lling-N.ndxh of faimoms 3 N/A Su@hvlelon Nanx
<br /> Black H
<br /> ❑ Public/Comtme Crd-Descnbe Use
<br /> N/A U (",I, of
<br /> ❑Sats Owned-Descul c.Use CSM Numbo ❑ Vlllhee of
<br /> N/A ❑ Tnwn of OHKGFtiD
<br /> D[.T}pe of Purmil (Check onl} one bax on line A. Compie(e line B ifappli,ii
<br /> A. Eeem ❑ Ke lamment Ss�em ❑ TmatmenpDnldin Tank Re ileconrnt Onl U Otber Modif¢atian m F.xiAing System p > g I Y Y (explain)
<br /> U. en wal 1i L'ermii Reunion ❑ Chan of ❑Permit hayskr to New Lt>i I'n,mus Yermit Numbu albemlsnedation Plunit," he,
<br /> IV."type of P01VTS Systcan/ComponeallNeviec (Check all that apph)
<br /> San Pos,ahrzcd In(hound ❑ Precmnzed In-Ground U A,Grade ❑ f4rund > PA in.oF,mohl, ,it ❑ Momrvf 1 241, of suitable_ou
<br /> �}1 Bad,,Tank ❑Other Dispersal Com' me,n(e.pinin) ❑Pretnsan,nt Device(,,plain)
<br /> V. 1) n11/'1'remmvW Area information:
<br /> Design Flow(gpd) pesion Soil Appheauan Rme( Ptst) Dispersal Arcp Required(10 Diepermi Ara Propoxd(sq S stem Elevation
<br /> 450 N/A N/A N/A N/A
<br /> V1."Dank Info Capacity in foal pot Mnnutacmmr
<br /> - Oallmu' Gallons Units JE
<br /> Nh'TmL Front,I ink, -
<br /> oU
<br /> sepor mr[fell Tank 3000 0 3000 1 WEISER X
<br /> 0-1 ng 061-1
<br /> VII. Responsibility Smd.nn,nt- 1,the unde,mn,d,n x,rae rexi,m ibility far installation of the M)\VI'S smvvct on the attached plans.
<br /> Plumber's Name(Print) P'lumber's ignamrc MP/MPRS Ishin"r Ruvn�s1'ho�Number
<br /> PAUL KOEHLER —/ 225410 715-246-2660
<br /> Pluttmer's Addmas(Street,Cha Sate,Zip Code)
<br /> 321 WISCONSIN DRIVE, NEW RICHMOND, WI 54017
<br /> VHL CounbdDc arlmeal Use Only
<br /> per 1IFF (o-lb�/f1
<br /> IR g Agent Sim
<br /> 7SApvmree El Daapmerd lP3p
<br /> O Owo-Covert heirs..,hu Dnia
<br /> IX. Conditions of Approval/Reasons for Disapproval
<br /> 2014
<br /> dttnaF to mmplem plmv far-1M1e s_rstM'e
<br /> BURNIM COUNW
<br /> ZONING
<br /> SBD 6398(R. 11/1I) ��
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