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<br /> Industry Services Division Sia .n eYv-
<br /> :Jr OS 1400 E Washington Ave Saniuly Peart vumhr(to ne tilled in by Co.)
<br /> P,S' (-i P.O.Box 7162 -57' gil�
<br /> ate: S Madison,WI 53707-7162 —J x /J
<br /> Sanitary Permit Application "' ' " Nuinther
<br /> In accordance with SPS 393 21(3),Nis.Adm.Code.submission of in,form io the appropri ut gnvommenval wit
<br /> is nquimd prior to obtaining zxaniary permit Note:Application hands lot zcd,-vwnsl POWTS are on, ded to Project Address(Lfdifterrfl than mailing uddtess)
<br /> the Dcpurmetn of Satiny and Professional Servics. Personal information you provide may be used for secondary
<br /> u
<br /> ccoae with the Privacy Law,s. 15.0t(I nml.Corte. 54 M6
<br /> 1Application
<br /> cation Inform atlon-Please Print All Information
<br /> Pmpeny Ownds Name Parcel aqa
<br /> - .B I- e ed 0
<br /> p7 -OaB-J,loo -1
<br /> J4m .1 �< o � 0r]OBO
<br /> Pinion,aty Owner,hlniling Addre'rs, Property Lawon
<br /> 1 Y 73 0, f, d - unit Lot ' -Sec•City,State Lipcwle Phone Number ,flVE A.U e, second ,f5
<br /> W Cy J / ,f4P73 (circle incril
<br /> 11.'Fype of Building(check all That apply) Lot p T qD N; R Iq E.6V
<br /> �
<br /> d( q lor2 Fatally Dwelling-Number n(Bedmln
<br /> os (Dor{ t -F Subaivuion Name
<br /> Block a
<br /> ❑Publi.Commereial-Describe Dsv D Cirvof
<br /> ❑state owned-Dc—tc llm CSbI NnmMr ❑ Village of
<br /> ® ,nwact X , ry
<br /> III.Type of Permie (Check onlc ane bus on litre A. Complete line D if applicable)
<br /> `\' ❑ New Sano 20 Replecemerl Sync ❑"I reaanor,11 old..,Tan,R,,Iheemcnt Only ❑ Other Modilieaion In Existing Systala(explural
<br /> It. D Perron Rerewal Cl Permit Ree isno ❑Chan f Phnnber ❑Permit Transfer to Ni,. D,t I'tevino,Permit a"mlnr and Date Issued
<br /> gc o
<br /> Befnn Eapimtixn owner /38y/ (7-2/-/j$8
<br /> 1\'.Y'v on of PO\\'TS System/Cam orient/Device: Check all 1ha1 a tiv
<br /> ❑ Noa-Preswnmd 1.Ground D Pre,cmmMun.armmd ❑ At-((rade D sound_24 in at suitable soil D Mound<24 inof suitable soil
<br /> Holding Tank D Other Disrersal Gnnpnnent(explain) ❑Ptetmrtment Device Fe.phinl
<br /> V.Die orsalfiremment Area Information:
<br /> Design Flow(gpd) I Design Soil Applicaion Rat,gplst) Dupct'sal Arm(tenoned On Dispersal Aran Purpoord p0 Sync HI-anon
<br /> VL Tank info Capacityin Total not Manufacturer
<br /> Gallons Qadlot Onus -
<br /> Seplic o.Holding Tank 4000 p10B0 / W/rJ < A,
<br /> ,'D ///}/U /aLu ( WC17 1
<br /> FII. Responsibilin-Statement- I,the undereilmea,assume responsibility for moudialan oftn<PORTS shcnun on the attached plan,.
<br /> Plumbor's Name(I'nntl P lunla:fe Signature MI'/hlPl(S Nnmbe, Fastness Phone Number
<br /> o Fie /,.. t / /s}js'i ?fs=866 -v/rI
<br /> Plummer's Address(Street City.State.Zip Code)
<br /> 7760 /1 , 3S W ,;S sf•._ (nJl SY853
<br /> VI 11.County/Uc artm can Use Only
<br /> Appr°vnl CJ DiwpPmved Permit Fee Daelssued Issuing Agent Signature
<br /> ❑Owner Given Remnn far Denial 3-75— 111 /5
<br /> IN.Conditions of Approaal/Reasons for Disapprmal
<br /> /G rGo/L 59Tc./tNl /hctS� 1>?0 9ycKa,�' LfrcL4(/y7Jrsv/J 1, r,17�7?1`7r�,('i'—�.
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<br /> vuo ta<amPla<pmn,rnthe a,tratAdd,amnu tathe cna 11,, nal.a.v.x..ot hrue,.evt flf11
<br /> 'm<r
<br /> J� V,
<br /> BURNETT COUNTY
<br /> SBD-6398(R03 13) ZONING
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