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Coaaty� <br /> Safety and Buildings Division l4 r i1 <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number Robe fined ins Co.I <br /> ' - 'Si _a Madison,WI 53707-7162 <br /> 566873 <br /> Sanitary Permit Application ate Transaction Number-f2 <br /> 1.acrandan- ,Ih SPS 383.21(2),wis-Act,.Code,snbmi„hm offn&r m no spin to goxemmemal ta” Z31 / <br /> ,requinJ poor ro obtainingvsanimry pertnit. Nice Application forms for state-coned pOU'fS are submitted to Project Address(it UitTereatmor rmaImgaddm,$) <br /> rile Depanmcm of Soren'atM Roftzsional Srrvies. Persomal inf rm ni.....D....do mm'be..it for seeoMarc <br /> accordance with the Priwev loo.s. 15 04H nif Stat, p� t( ..(( <br /> l. Afill d tion l n form a tion-Please Print Nlmformation 70-J / i�dl Ce�•cklS <br /> Rofrm'O.,ner'x NameParml a <br /> 1jets -� Signe oer ei :. 67—wig-a3 -ii-D7-y <br /> Propem Oomm's Moling Address I Pmpen.Location 01-00 -01;7.000 <br /> g4S" Co-„ �. D Gcni Lot <br /> Cig•Sum zip Code Phone Number SE it, S E'/. Saxton 7 <br /> lw Ul; SFb 911S gbh" kms '�q mimlenn <br /> li.Typo of Building(check all that apply) Lme 1' N: REet w� <br /> f ort Family Dwelling-Nomlrcrof Bedrooms 3 ruTdixision Name <br /> Block e <br /> ❑Publi✓Commocial-De,eobeU,e <br /> ❑cox of <br /> ❑Store Ginned-Describe Use CSSI Number, El Village of <br /> �(l'own of_I'v t.FF h o f� <br /> I II.I3pcofl'ermi : (Cheekinly one boxing line A. Complete linen fapplicaMe) g_ <br /> •x" DNew S„tcm 'x Rcplzcemam System ❑TremmenNleming Tank Replacement Only D Ocher Nic,iriessinn m E—fir,sysrem explain) <br /> R. D Permit Rern..al D Permit Revision D Change of Plumber ❑Permit Tram For ma' List Pmximu Permit Number and Doc Issued <br /> nelme l&piration Gomer <br /> I\.'rx par of P0%%1S SstemlCom n enUDexice: (.heck all lhala k <br /> D Nom Vo,,arieed 1,43 and D Pressurized ImGro•md D At-Gado KMound>24 inofsuimble soil D Mound<2a in.ofsuarble—I <br /> D Holding Tank D Other Disposal Component(explain) D Pretreatment Dcvice(c.plainl <br /> \.Ills rrsal/1'rearm em Area Information: <br /> 111..also) Design Soil Application Rate(epil Dispersal Arca Required(.st) Disposal At.Propend PH System F.Icxution <br /> Sa l I 11I yso 1 LS <br /> %I.'I'milk Info n <br /> Capac Total 4 o mommoca.— <br /> Gallium Gallons Units <br /> yrx Tanks Fv,iing Tink, o <br /> o R " <br /> uV <br /> seq�r ..1sn cork OIP P " X <br /> %IL R......ihail, $mtement- L me under.isn d.ae,umc resryrnsibilir.for inaallmiun of the 1'IIN'TS aho,.n on rile ananc�d clam. <br /> Plumber's Name(Printl PI moor's Signature' hi Pl,\1PRS Number Rosiness('hone Number <br /> I Z2'S22 lij r�(o 6-, 0,� <br /> Plumber's Address(Staet,City,Sure,LIP Goaq <br /> -1845 eb %1' S x/ <br /> VIII.Connrv)Dieartment U,rkfifl, <br /> idApprm'ed DDisappnnaJ Parm>iitFtt Dote Issued fission,Agent Silicon c, <br /> ❑O,,am Given R-.,,lot Denial S >7r.00 <br /> IS Condition.oL\pproca UReasons for Disapproval <br /> p EC�OVE <br /> Inn <br /> nn <br /> Anson to romvbb all au th noesaad,.nmu m the Cents,, ono on YPrr not man a v:a IIwill <br /> SRD.6398 HR. I Ul 1) BURNETT COUNTY <br /> ZONING <br />