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County y <br /> Industry Services Division �tn.^�Lr7/- <br /> (Yt OS - , 1400 E Washington Ave en <br /> Sa arms,Pal Ntni po be ruled as by Co.) <br /> PS PI P.O. Box 7162 <br /> Madison,WI 53707-7162 ]�� /�(7� <br /> s V'l �d <br /> Sanitary Permit Application Since Transaction"ulnar <br /> In acmmicnm wish SPS 333.21(2),W is.Adm Code,submissiar of this form to the appropriate govemme:nal all <br /> is req - d prior to obtaining a openspe t Note Application fornsf '.tat dPOWT$are sabnnedle Pmject Address(ifdflcmnl than mailing address) <br /> the Diparmarreent of Safcry d P ofeesional Sery res, Pecohind Information you provide may he head for secondary d 9 686 <br /> u srernevoNaneawishNePrivacy Law,s. I5.di(l)(.i Slams_ <br /> 1. Application lnformation-Please Print All Information /", Atee, f <br /> Properly Owner's Nan, Pmccl ft y�_/mS-35- S-oS- <br /> .�a✓e Id a�_o3a-> <br /> vo6- odl ono <br /> Property Owner s Mailing Address Phi Locmlrn <br /> cnvt.Lit 6 <br /> City,StamZip Cwle Phone Number ,pt✓ s, SE t, Section 3S` <br /> 11.Type of DuildinC(check all that apply) Lot p <br /> I or 2 Form ly Dwelling-Number ofbedmmm, / South ..am Nvne <br /> Block p <br /> ❑publicc Comnmrcinl-Describe Use ❑ Cayor <br /> ❑him,0—ul-IXspnts,Ilse CSM Number ❑ village of <br /> V. 9 P R Town nr -rW tss <br /> R,111.Type of Permit. (Check only one box online A. Complete line B if applicable) <br /> A' ❑ siSysrem KRepl—rinern S,hnh ❑ h ending Tanua <br /> a,haTolk Replmmo Only LJ Other F <br /> Other Modification voing System(explain) <br /> ❑ Permit Rennvul ❑ Permit Revision ❑Change of Plumber ❑Permit Trhosrere,New Lea�PPeyion,Permit Number and Dam d <br /> lssuc <br /> Before[Amashot Owner Zpp 91/Ss- <br /> IV.Type of Pi Svstem/Com onentlDevice: (Check all that apply) <br /> Nov-Pressurized 1.Gourd ❑ I'm ssun'zed I.Gmone ❑ Ar-Gmtle ❑ Nemed_>24 in,ofsufmblo soil ❑ Mound 124 N.spendable soil <br /> El Holding lank ❑Other Dupersal Component(explain) Q Pretreatment Device(expluin) <br /> V. Dis cream/Treatment Area Infurm:nior: <br /> Desigm Plnw(gpAl Design Soil Application RaeNo Dupersal Amea 14quircd(sQ Dispeonl Area Purposed(sp Syxlem F.levPtion - <br /> 4 _ . 7 <br /> Vt.Tank Into Capacity is food dof March, nt <br /> Galles Grdlom Units _ v <br /> tw Tao�e Furtinp Taal¢ - e <br /> tu <br /> Septic or calasg Tank <br /> 1)mimCM1amber r <br /> VIT.Responsibility Statement- I,the undersigned,muchre reapnndbility fur installation mine PO\STS slmen on the attached plans. <br /> Plumber's Name(PrirpPluummber's'Sigencip,/ 7FMPRSNumber Burmese Phone Number <br /> �eG/G 7er„J �Gu�-� /Y d.{S�.S/ 7/-11 <br /> Plumber's Address(.trea,Ciry,Sale,Zip Code) <br /> ) 7760 16/ 3.S el ea6Jf r.. W. SY[S"5s <br /> VIII.Conn /De admen!Use Only <br /> 19 Approved ❑ Disapproved permit Fcc Ihtc lssuetl Issuing Agent Signmum <br /> ❑ Dwnarc-en Pecaeea fir Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 5Y5TE`to 467V. /Wgi !3E #,-zow ort6xxtw 5K7V" A662E317r" t<'e���} <br /> ANY UoGG/n/G MHT. D ECO 1JM <br /> E <br /> CsT�ly- I .\rta[hln[ mplerePl'emf�rt mnnrlmhmutorheCnu only npaper�at)era[hanPr_il 9 <br /> SBD-6398((R03133)) BURNETT COUNTY <br /> ZONING <br />