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<br /> CounK
<br /> i Safety and Buildings Division e�/`N
<br /> 10 \° 201 W.Washington Ave., P.O. Box 7162 Sunitrav Pcrmh Number no be filled in by Cul
<br /> �e\>, Sit I? Madison,WI 53707-7162 01
<br /> Sit Madison, a58 93 S �
<br /> Sanitary Permit Application mlrw mne`
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<br /> Inaeeo,d.ac,,im SPS383.21(2),N'is,Adm.Coda,submirion of this formblhe appropriate governmental unit Y rQ.VICt.J
<br /> n reyuirN prio,toobtvining a su ni, xrorit. Nntc:Application fumes lar state-o un ed POWTS are subnnded to ]'reject Addr,ns(i fdif aenthan routine address)
<br /> the Ucpanmad ofSacty and Prufessooal Scenics. Permnal infirmenion you pro,ide matbe used for secoodaen
<br /> comanae.dm mel+hae.I.mcs. 150,10Nm).Sut.
<br /> 1. Application Information-Please Print All Information
<br /> I'n... ny Ouncr'a Nnmc �[ I'arc09 CD7o/.z-a 6�3-75=5
<br /> wA Ael.- fS 700 o/lP»O
<br /> Pmpeny o.mer's Sailing Address " .. panned)Lucatian/ .l,
<br /> you 7 C—,e� A d Gm,.Lou
<br /> One.State /lip Code phone Nwnbcr y,. 'A. Sectio
<br /> IJ /5 /ter W.r Sy973 Eon
<br /> ldrdcone)
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<br /> IL'1'y'pe o(Build inF(check all that apply) �f Lmq f�N: R�
<br /> -1 or 2 Fami he Do hot,-Numb,of Dedr«,ms O` j Snail Name
<br /> ❑Pub11c1Commereisl-l) s,,ohc Use ❑Cin of
<br /> ❑State(.aod-1Xs ,ibe Use CSM Numhr L1 village of
<br /> III. )'peof Pc,rnit (Checknnlynnebuaonlinc A. Compleleline Rifnpplicahle)
<br /> \' wSyumv El RePlacenwnt Maem ❑Tre:nmrnUl lolling l'wk Replacement Only ❑Omer Mtditicmion to l!sisting Syzmm k'aplain)
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<br /> R. ❑ Pcount R,ae,al ❑ Permit Recision ❑Chatge of)'lumber ❑Permit l mmlcr m Nc, List Praciaus P,non NumMr and Date Issued
<br /> 1leknc kepi...on (hater
<br /> IV.Type of PON IFS STstem/Com onrnt/Uevim: Check nll thnLt h
<br /> Von-Pressurized In-Ground ❑ Preszuriicd Iin-Ground ❑At-Orade ❑Moral I 24a of suitable soil ❑Sound 124 inof suitable sail
<br /> El Holding Tank ❑Other Dispersal Companem(crplaiip ❑Pmreamtent Ucsice c,d.in)
<br /> V.Dis ersun*reatment Area hdnrmation:
<br /> fksign flow(gpd) Design Snit A,ohlation Rme(gM,fi Di, ,sal Area Rryuired(s0 Ilo,a,nl Arco 1'ropwed pt) S)clnm IJomion
<br /> Sob 17 1 eli,29 yso q, so
<br /> AT I'ank Info Capacity in Tmal root Manufacturer
<br /> Gallons Gallon Units
<br /> New Talk, F,. ov Ta k,
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<br /> Scenic ar nn161..�
<br /> Ihsinp lbambct
<br /> \'11. Rots ponsibilifa'Slalenumt- L me nndeni;nN,assume respan.ibilin for installation of the 110\YI:S shaan nn the anachN plans.
<br /> Ill unthe,,Notre(Prior) Matter's Sarac uue MI'IYtPRS Number Dusiness)'hone Number
<br /> Plumber's Address(StraL Clo.State.zip CWO
<br /> /J e s/y S-//'C - a✓-t- sYS72
<br /> VIII.County/Depnrtmeat Ilse Only
<br /> \pproued Cl Disapproved P9mtit I r, Data ISAmd Issuing A .ignmum
<br /> ❑ owner Given R,;,,,a]or Denial 53�5'�� �FrfC.2o13
<br /> I.C.Conditions ofAppnrval/Reasons fur Disapproval
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<br /> LAPR 22 2013
<br /> AtweM1 mmmple,plan,Nrthoyoin ankunnii to me Cnu _ on,wn PaPernat lasulm.8... 11 n nsae
<br /> BURNM COUNTY
<br /> Slt )-6398(R. 11/11) ZONING
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