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' I <br /> County <br /> Safely and Buildings Division <br /> 1400 a itl P <br /> E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> la sp•1 P.O. Box 7162 <br /> �^ S, ar) Madison,WI 53707-7162 <br /> •=yam/ s <br /> Sanitary Permit Permit Application Stam TransactionNu b= <br /> In accordance with SPS 383 21(2),W is.Adm.Code,submission of this form to the appmprimc governmental unit <br /> is requited prior to obtaining a sanitary permit, Note:Application forms for state-owned POW]S arc submitted to Protect Address(if di lberem Nan mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary b/�v llj L 0i s <br /> purpo,es in accordance with the Privacy,law,s. I S 04 I m,Stats.. <br /> I. Application Information-Please Print All Information <br /> Pro ownerls Nampa ,f Per of a <br /> llyo/ / ,ucj,— - Si o ZZIdd <br /> Property Counter's Mailing Address Property Location <br /> a6/ le— 5 Govt.1.1 <br /> City,Smte=/�" 7/ / 7.ip Code Phone Number /,_'A, SectiongL, <br /> /�Y/s: (icJ. SYSIyO T _7R.e 1. <br /> O N; <br /> 11.Type of Buildingfelieck all that apply) I,ot a <br /> I or 2 Family Dwelling-Number of Bedrooms -;2- /.�-- �/ Subdivision Name <br /> � BI«ka ,4N So.�S S <br /> O PublirrUmanx cial-Describe Use ❑ City of <br /> O State Ownrd-Describe Use CSM Number El village of <br /> OTown orei- <br /> Ill.Type of Permit: (Cheek only one box on line A. Complete line B if applicable) <br /> A' ❑New System fiRrplacement System OTremovii bolding Yank le_-ploseent Only O Other Modification to Existing System(explain) <br /> B. Cl Permit Renewal 0 Permit licvision ❑Change of Plumber 0 Penou i'rerolm to New I'or Previous;Pcoma Number and Date Issued <br /> Before Expiration Caner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> O Nun-Pressun,ed In-Gmund El 11ressmiv.cd In-Ground O At-Grude ❑ Mound>24 in.ofsmuible soil OM...J<24 in.of suitable sail <br /> AIkAding Took ❑Other Dispersal Consponem(cxplain) O Pretreatment Davice(explain) <br /> V.Dis ersallTreatme at Are. Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpds0 Dispersal Arca Required(s0 Dispersal 7P�rdWS,jt��.pDVt.Tank Info Capm;dy in "fare q oI ManufaGallon Gallons UnitsNew 1.W Esixon8'runiiU d <br /> �pworlmleinaT.nk G?oa0 — <br /> uosma Chambre <br /> VII.Responsibility Statement- 1,the undersigned,usunre responsibility for m1orlafon of the POH'15 shown un the attached plam. <br /> Name(Prior) Plumber's Sign 227691 RS Number--FH— <br /> Plumber's <br /> WADER Name(Pri MlIM ]IS -]286 <br /> Plumber's Address(Strst,City,Stale,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> VIII.County/De artment Use Only <br /> Approved ❑Disapproved Semtit Fee Date Issued Issuing Agent Signature <br /> 375aa (o/6-A/ Lee-'; %ate <br /> 0 Cwner Given Rteawn for Denial <br /> IX.Conditions of Approv l/Ressum for Disapproval �I�] •i��'•?•�_\ /t? <br /> /�///(/ 56T641-� 771 c✓ELG ,057- &C /HET /144"O /A..Y.r 7V ii •PUJ ] l �- JEI <br /> l11. ll JUN 1 fi 2014 <br /> Ansm m<omplete pbm for the system and submit o the Counryonlyan uses,net lea than stn Ilmrta <br /> BURNETT COUNTY <br /> "' <br /> ---- ZONING ZONING <br />