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County
<br /> /-.�•; �!:. Industry Services Division "vn e?-/'-
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<br /> ;3r10 '= 1400 E Washington Ave Staryen
<br /> Penna Nn:tthe,uo be fllnf in by Co)
<br /> \S p�S`,,. 5,'1 P.O. Box 71621"-I�I�JJ�a
<br /> Madison,WI 53707-7162 _J / I -T
<br /> Sanitary Permit Application State I larra,una Nlook,
<br /> In n d-ov with SPS 39321121,)vis.Adan Calc,labor oRbis tuna w the a,Iwvaime ger emaneraluna a v'(`(5
<br /> s required pinna obolnin6nsan an,Pennil. Nolc'.Application termsl'or, 1.1e ,,.,d POW IS an,-umitlul In PntjeaAddn,,,li ldiInnl Nmt ntnlling address)
<br /> the 1),unmem of Safety and Professional toanka. Plasmal infonnmion you pmviJe may be used for secondary
<br /> eanmana with mg rn.ann t.aw.,. Is luphml.stale. 64R-0
<br /> 97 vN ;ds.W
<br /> 1.A plication Informanion-Please Prin t All Lt formation
<br /> Proparry Owner's Name Panela /b-da-S 7S'073
<br /> S
<br /> 07-ord.a- 35_
<br /> GVC 7o✓jcn $o h . ed8e00
<br /> Progeny Owner's Mailing Address Property I onaoon
<br /> 949 RI I/a < LI-n Go.t.Lot_
<br /> City,Sulo Lip Code Phone Numh
<br /> —'I, :, Senian }
<br /> fawn �a�t �/V SS3o & (cinvone)
<br /> 11.Ty pe of Budding(ehsek all dust apply) Iof9 /(z_EnV
<br /> � IOf2 Family DwcllinS-Nn:nMrof Redmotm /g S.Nfi-.onNana
<br /> Black p Ga7/1
<br /> ❑Public'Commercdl-Desmh Ilu
<br /> ❑Cm of
<br /> D sate Orated-Oeserihe Dse CSMNmnhr D Vllingenf
<br /> ®'Tenn of
<br /> III.Type of Permit: (Cheek only one hes on It.,A. Complete line 6 if applie.ble)
<br /> A 11 New System A Replacmrnt System ❑Ta,,aaaellolding Tank Repbcemeat Only D(kil Molifieaion m Listing Sysnrtn lerplainl
<br /> R. D Pial nil Renewal D Pen»it Revision D Changeol'Pll be, D PenniI I'mmd,to New List Ptevinm Pennil Nanber and Dale Issned
<br /> nefum Eapimtion Owner
<br /> IV."I\' a of P0sATS Ssslem/Com .neat/Uevire: Check all nhnta k)
<br /> 11Non-Pmssnrv4J In-Ground D Presean,vd In Ground DAt-Glade ,0 Mound>34 in.olleitabte mil E)Mound<24 in.of suitable mil
<br /> D Hohhe,'lark 001herltis(wrwl Cnmlror,m lcapinin) D Prcirenintent Ucvice(explain)
<br /> V.Dis ersaITIrealment Area Information:
<br /> Design Flow hdxiI 0. Lia)Soil AVplieolion R ingpdst) Dist<rsal Area Requinv kh UispetsaUrta Pmposed(t) System Elevation
<br /> -70 1 . , Cl yell 3 1 47 •! J
<br /> VL Tank Info Capacity in f)nal dor Mnladamr.r
<br /> canon Gallon units
<br /> ]ow 1'.n:ka l i� my Tanks _ �
<br /> ]optic or landing Tank bees (COO
<br /> Dosingenumber ,5--60 1 ,)Co
<br /> VII.thoiensithilil, Statement- 1,the mtder,igaed,assume respnaahirty for installation or the PO\VI'S shown on the ammhd plans.
<br /> Planner's Name(Pnnl) I'lu:nb:rs SSignature/J hlI4hIPItS lhm , Btu'oe"Phnve Number
<br /> R/ 4 ..p 7eln IC r..J �c�r-Gr-�..(� Ja r}rFS'�af 7 7/,s-' "/J-7
<br /> YIumM'x AJJtucs f Sanwa.Cit},Slate,Lip Code)
<br /> 77617 �/ 3S G/ebs7'e S$S 3
<br /> Vill.Cnant,/De artalent Use Onlr
<br /> Appmv4d ❑ Disapproved Pmm'17- Otte lss�nJnf E,aiinng Agan Signa¢
<br /> D Owner Given Reawln for Denial �75� �•(D��y lllw;/
<br /> IX.Conditions of ApprocallNeasons for Uisnppronof
<br /> DC cEm
<br /> QST 14 go_ \lural. mpmaplam ror lh<s, mmnsuemit t-t.Cvt , etas npap renik taaaga-a 11 nwaer `
<br /> O ,.f1N
<br /> BURNETTCOUNTY
<br /> SBD-6398(R0313) ZONING
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