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Coanly Il <br /> Safety and Buildings Division Uf zj. <br /> i O S PI 201 W.Washington Ave., P.O.Bax 7162 Sanam,Parent Numbs(m be filled m by Ca.) <br /> \ P Madison,WI 53707-7162 <br /> 11 xSi ii <br /> Sanitary Permit Application SmeTr/M/y/y anNumbeet <br /> In zccvndaae wim 5P5 39321(2),Wix.Adm.Code submicron of thu form to the approprime govertwrnml wit GN"r�l I ,evle(A) <br /> is mquirnl prior to aMaiwag a smitary icrmi. Nae:Application forma t nareou dPDt are nrbnoundm Project AM.l ifdi Ream than mailing address) <br /> the Uclvnment of Safety ami Pmfeaiorml Servies Pems infwmmmn yaa movide rimy be mcd fw aewtdary <br /> accordance with the Priva law.a. 150ell m-Sats. <br /> I.rAreuenn lnformnlinn-%ecru Prinl,Vl Information LD <br /> Prnperty0•mer's Name Pamela o20-4323-e3-Yoo aayxr N <br /> vt N 4- p7-090-2-40-&-B-5 05-DOI-04CM <br /> P,.,xrtyaamr's Mailing ddre- - Proper,Location <br /> l zql Gaa Lat / <br /> City.Sime Zip Code Plane Namba , <br /> 'l /, 'A{,�Section Z� <br /> 696 /u 515-038 651- Cr5 --/;#w T!O N; R�I[o� <br /> U.Type of Building(check all thatapply) Lola <br /> ❑ l or'Family Duelling-Nista ofMr. Subdivision Name <br /> Black a <br /> ❑NblidCammcrcial-Describe Use ❑City of <br /> State Owned-Desnle Use CSM Number 0 `/illa8e of <br /> U ' n7/ 7 I9(Tmvnof 6,11:A rd <br /> ill.'I'ypeof Permit: (Cheekonlyoor boa online A. Complete line B ifapplYieablle)) <br /> A. ;INry Syetcm D Raplacemem System ❑T...Ololding Tank Rapl:ememotdy DOmer Mxtroadw m Limina System(-Ploin) <br /> R. D Pandit Rercwal D Permit Revision ❑Clmnge of Planbe ❑Pmwt l'tansfer to Ncw List Prtvian Permit Number arta lAme lisuN <br /> Before Expiation <br /> IMV.'1'a a of I.O\V'fb 5vtem/Com ones UUeviee Check all that a H <br /> W Non-Preaadaed lM muni D Preaudnd In-Gmtaid D At-Grad, D Mmmd[>24 in.ofswmblesoil D Mound<24 in.ofsuiwblewd <br /> D1lolding Tank DOdmr Dispersal Compomnt(oxraain) ❑Preaemment Nk .ce(explAm <br /> \'. Itis enalRremmem Arta Information: <br /> Deeien Flnw(,ad) Design Soil Appliamon Rmggpdm) Dispeml Arm Rtyuirtd(sf) Diaperaca P <br /> l An. System I levation <br /> 3� 7 Im yZ - 9380 <br /> NL 11nk Info Capac e,in Teal aof Matmfaturer _ <br /> Gallwts Gallas Units a Y N-Tacks Faisiq Tads <br /> Sce.,a Meta°,Tam, XGeon Y <br /> Donn,I .bu <br /> V'11.Re,mm sihilil,Statement- I,the modereigned,ao n.ctl,mtibility for installation of the MNVI S shown on the it.kohed Plans <br /> Plasha�me,IP,inO Plum 'igratwe MPIMYR$Number Umincss Phae Numher <br /> s/c r�r er i 5155 1 T/5 7a <br /> I'lumber's Address lSumt Ciy,stare.ZipC 1 <br /> 27120 Tq�nf� J WC`5�e/w:544 <br /> \91 Conn laNc artmanl Use Onh <br /> ApprovN DDisapmovN Permit Fee 4� Ihte''I/ss/uN Iswitg tgreture <br /> D U;ner Given Reason for Denial S 5.252 gM4✓2aY3 <br /> IS.conditions of App Fovaveeasans for Disappem al <br /> p ECEd� <br /> .um.a mramwate ntaa.ran tlw.,nem.at am.mlt mthe eaaaty amy at wpe.a.,l,..m s .IMA�ra cage 2013 <br /> SBD-6398(R-11111) BURNETT COUNTY <br /> ZONING <br />