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e.a" a County <br /> j \�\ Safely and Buildings Division <br /> �5,' ` 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> PP.O. Box 7162 6-77-94W <br /> i <br /> '� / I Madison,WI 53707-7162 <br /> "<ymNxi'� <br /> Sanitary Permit Application State Iradiation Numhcr <br /> ni <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission afshis]form to Our appropriate govcnauenml ufit W6SoLS <br /> is required prior to obtaining is sanitary permit. Note:Application forms l"or sunt-awned POW17S are submitted to Project Address(ifdiai)ent Nanmaibng Mdrese) <br /> the Department of Safety and Professional Services. Personal infomution you provide may be used to,woundory <br /> ,.,.as in accordance with the Privacy Iaw,s. 15.041 m,Stuns. rtJ <br /> 1. Application Information-Please Print All Information <br /> Properly Owner•s Name t Proccl9 o7 O 7 <br /> Property Owner's Mailing Address �) Property Location <br /> g" 8/ s q, ^?; l s'/, /,,✓) Govt Ixt <br /> City,State Zip Code Phone Number --A_-/, Section <br /> 0 (circle one)_ <br /> IL Type of Building(eh oak ell that apply) Ot 7 Lot H T�N; R /L Ea,•C�Y7 <br /> �or 2 Family Dwelling-Number ofBecrooms / Subdi sion Name <br /> C <br /> �. Dlook 11 �.1,9ln L/j'hC P,yti�5 <br /> ❑PublidCommcrcial-Describe Use ❑City of <br /> ❑State Owned-Describe Use / CSM Number El village of <br /> kr7'own of fy 0^J <br /> Ill.Type of Perm It: (Check only one box on line A. Complete line B if applicable) <br /> `4' ❑ New System epinconwnl5ystcm ❑ 'I'remmenVllolJing Y'xnk ltopl:memmat Only El Other MuJincmiomm�xisting System(explain <br /> U. ❑ I'crmil Rencwol ❑ Permit 12cvisinn ❑ Change of I'Iumbcr [It'crmit'I',ruwfe,to New List Previous Permit Number and Date Issued <br /> Before Expinamin Owncr <br /> IV.Type of POWTSS stem/Cam onenUDevicc: Check all that apply) <br /> ❑Non-PrecsurivcJ lnGncmnd ❑ Pre ssurimd I.-Ground ❑ At-Gmde ❑ hluand>24 in.ofsuimble soil IJ�Mound<24 in.ofsuimble soil <br /> 0hilding Tank ❑Omer Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Diss ersoliTreatment Area Information: <br /> Design flow(gpd) Design Soil Application Ratee xis f) Dispersal Aren Requird(sD Dispersal Arco Proposed(sf) Sysum Elevation <br /> /.0 30� 3ov , s <br /> VI.Took Info Capacity in Iatal Hof Manufacturer <br /> Gallons Gallons Units <br /> New T>n4aE.w.,Tan4a y 3 LL <br /> au° unO <br /> Septic iii.Ung T.ak /d0e) <br /> nosing Chamber <br /> Kc <br /> nsibility StatCem ent- 1,nm undoaigaul,taunt responsibility far Imstallatiun of the PON'IS shown an the attached plata. <br /> Name(I fin) Plumber's Signa lure MPRAPRS Number Business Phone Number <br /> SHOLM / 227691 715-349-7286 <br /> ddress(Street,City.Slate,Zip Code) wet <br /> 4,SIREN,W 154872 <br /> IviDu arhnent Use OnlPermitPee Dae lssncJ Issuing Agent Signnhtre <br /> d ❑Disapproved s '37S.00 L0,/N9// <br /> ❑owner Given itcmun for Dettml <br /> IX.Conditions of ApprovapReasons for Disapproval <br /> -/Yee S7, " iso' Flaw, WeUt S, <br /> .inuSf NAU6 Aay/uvn/-l4JRT&RTl6N>✓ oPENlv�S AT�HBouG 95Sao' �iI <br /> CS'(-I�'I(`p ntmd,t...n,nl.mta.nt rortberl""ra-d-duaamtbe Co ann'ony on a.prrnotlrsanine n.fu n t ,IV,i <br /> D u LJ <br /> _ --.. ._..... BURNETT COUNTY <br /> ZONING <br />