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Jyja��pr� Counly� <br /> l +�!? Industry Services Division car rl six 7y <br /> 'j", 0 1400 E Washington Ave Sanitary Penal Nmnber Do he tilled in by Cej <br /> 11 Spy'+ pi P.O. Box 7162 r1r7 ,/3'7I <br /> ' Madison,WI 53707-7162 3 / 0 <br /> `tiw <br /> Sanitary Permit Application Sure "'nano"""'tib r <br /> In acmrdenee wish SPS 38321(2).Wis.Mai,Code,subir inn of this tarn to the appmprime dovemmcrid unit <br /> mrnptired prior In obtaining a.vaitary permit. Note mu Application for nate—id PORTS are submitted to Project Address(it ditieren than twilled adds <br /> e Dcpanmcnt of Ssfny and pmfeaninnal Servies. personal informmion ynn Provide may he used for ocendary d76(O <br /> u s s m ao.oltnce wish the privacy Law.s. 15 6i(1llml.Stats. L <C r �� <br /> I. As lirntinn lnfnrmalion-I'd...Print,\Il lnfornmlion <br /> Proem Owner's Name Parcel a _ <br /> M-, /e /3 Gr tn.t n G7 etJ a- ao'rfs A 017000 <br /> In.""Owner's Wailing Aa rims Property Location <br /> S8.10 L0mlJ Are- coy" [.or v <br /> C�,i.ty�/.Sure ziv ewe Phone Number �d, A, Section J � <br /> 14,r +'1rI"A k1 In IV SS yS _— (eimleane) <br /> II. N. R <br /> Tyre of Building pp SG �Lome <br /> I 4lcheck all thanl hl Lar IX T <br /> E91 ore ramdy thymins-Nnmbcr,ofBedromms H I -t 48, IAT d— s"bdiyainn Name <br /> block a <br /> ❑P"hrdcnmmereial-Docrinn ore <br /> ❑ risen( <br /> DSeceOwmd-DerenhcUse ('SMNumber ❑ Village of <br /> I Pr3� fil Tawm"f K <br /> 111."1'ypo of permb: (cheek oohnuc boa on line A. Complete line B if applicable) <br /> A. L)N,—System Ir Replacement Sysnm ❑Trcaunenrlfhill Tank Replacement Only 11 Other Mmlibcaion m Elsie,Systean(eaplain) <br /> it. D Penult Renews) D Pennh Revision D Clea,of 1'1lunbcr ❑Permit foarfer to New List ox,nus Permit Number and Date Isued <br /> Before fspirition One, <br /> IV.Tc pic,of POWlB System/Com onent/Urvicr. Check nil that."Pill <br /> 9Son-PreasmbedIn-Ground ❑ 'resraixdlrvlrannd D ,VGrade 0Morad124inofsnimblefoil ❑ Mound<24in.ofsterablesoil <br /> ❑Ilrlding'real, ❑Otter Disslersal Componrn4eaphinl ❑Prtueamaent Dr im(vsplein) <br /> C.Dis ersaVrrealnient Area Itlforomdon: <br /> Design I hem(Still) Design Soil Application Rate(BML.q DisPerval Area Renamed(s0 Di"i,sl Area Prapmd W) Srnem Elevodon <br /> el 00 . 7 8S7 1 yb'I I 9�4. O <br /> V1.lank Info Capacity in 'r"lal it of M1lmmticaner <br /> Gallon Guinn, <br /> Sw Ilnk+ to len Te k' - <br /> O g N <br /> Sa%io°rllaltlin6 link f—p /J,•$`0 / WaY 3'er J< <br /> Dever,Clnmrce <br /> \'I I. Responsibility Statement- 1,elm undersigned,assume responsibility for install"tion idly,PO\PI:S shon'n i n the attached plans. <br /> Plumber's Some(PnnD Plumber's SSiSrlamnre [ AIPl.a1PRS Nmmlur business Phone Number <br /> R;c/C //-10/ern-fir /Gce/'~+C /-1� n}�-r85'1 7/S- �GG-4/J-7 <br /> Plumber's Address(Street,City.Stine.Zip Cade) <br /> 776 a N .3S W eG. /'- <br /> VI <br /> '-VI II.Cou ntdUe artmon,Use Only <br /> \pprovd ❑ DisaPpr"ved S ZiZPeri 'Soo /DuOe Bawd ling Agent Signature <br /> D Owner riven Re>4,n for Dalial r/0-/[/ ett <br /> IX.Conditions of Apprncal/Reasons for Disapproval <br /> p EC EIVE <br /> CsfISI n/ .\nae01.1-1.ae plan+for or,—11.rod ahmia la la,Cointyooe on paper n or lv+f a hrnfl -0rt <br /> SBI)37oy(RD31133r)/f/rte BURNETTOOUNTY <br /> ZONING <br />