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` <br />Indy Services Division <br />I�WtWsdinowAvv <br />P.D. Box 9162 <br />Madison, WI 53"7-7162 <br />Comity <br />13utwe- T <br />Permit N (to be fii ed in by Co.) <br />&Q 68 <br />-5A - -av <br />SaI11tal Permit Appilic ilOfl <br />in accordance with SPS 383.22(2), Wis. Adm. Cade, Worms ian of dds foto to die.:.ppraprigdc WwanmcuW unit <br />is w s sera fsg pmt. NOW l s irr st sed i as lrr <br />the Department of Safety and ProfmwW Services Pe sxsi mformabon you provide may be used for secondary <br />in aoco[dmtsx wah the Priv raw s. 15. i tp Stas: <br />T *^aNaertirer <br />CSAM� <br />l <br />L p; s WeraosE� — Please Puri AB Ia�rrmsr ow <br />Property <br />�� <br />(�/K91, -"leis <br />D 1-Dib-z-.3`i-17-�s_ 3 0.3 Doo -olio <br />t� <br />Property thrier's Multog Address <br />E)4:;, ooK RD <br />Property Lavation <br />rte. LA — <br />5W /., Std ''A Sectitm �S <br />(C1r!-w <br />T 3q N; R 7 Eor V) <br />city, State <br />W LTS518k wz <br />Zip Code Phow <br />,5/-,/8 <br />Number <br />715-S46 - Z 786 <br />Ti. Type of slai dirq (el an 6 tib apptty) <br />I or 2 Family lhvdiing — Number of Hedrotnntss oo <br />ONS <br />0 Pdeticroranereisi -- Descrme use <br />0 Stow OWnW — Describe Use CSM <br />A <br />"— <br />SubdivWonName <br /># <br />0 city of <br />O Vida of <br />;ZTtiw,ncrf UNCouif <br />Number <br />III. Typo <br />of reretit: (Cieck easy ese b"He A. Ceapete Wee B ff awe} <br />A. <br />I'VNewSysteat <br />0 Repiaotmest System <br />0 TreeMeoffloiding Tank Reptacement 0n1y <br />0 Olber modification, to aistinB system (awk") <br />D. <br />10 Permit RwMid <br />BeFic a F. virntim <br />0 P+xmit Ravision <br />0 Chmnge of Phmnber <br />0 Ptrout Transfer to NOW <br />Own— <br />ISst P'rovious Permit Number and Date beans <br />W. Tyse <br />of POWTS aN <br />0 d 0 Pm, � 13AsOosk 0 � 24 im efssWAosed 13 Mom sd<24 in. ofnioalrle srnl <br />0 Hddmg Task 0 (Rha Dispersst Campoeent (expmin) 0 PrWataie ut Dew= (explain) <br />V. r tr rtnaesrt Artie fer awdoe: <br />Design Flow (Wd) Design Scd.Appiicat- itste(gpd <br />/d (� • <br />Area Rapared (so <br />/5! 29 <br />Dispe sat Area Proposed (at) <br />/�(� <br />System Eievatioe % <br />9� 7i� <br />VL Tarek 110% Capacity in Total <br />Ceruses <br />New Takla Eich*Tadw <br /># of maoulactulm <br />Herts <br />�u <br />r� <br />tie <br />g� 3,�x <br />VII. ettt- �, fie ibrrsoiar •ice POWTS Rase ea fir sffadied plan& <br />f'teel�r's <br />ie��l%`lll?f!�"1/t3�hssdrsF <br />ii!'lserest�lYrasber <br />774 <br />0 <br />Phmnber's Address (Street, City, Std Zip Cade) <br />9--366 gbfek ERO-OK J?onVU. <br />Q <br />0 Owner Given Reason for Demi <br />Penni,Fex Q <br />3 75 <br />nate issued <br />11-27,17 <br />Issuins <br />3 <br />DL Coediden of 4pprevai/Ressous fen DisaWavd <br />AN"iselsAr*$Ors"aniseAec"010abwp"WnotidsGoes InIII Wel" <br />• NOV 2 7 2017 <br />SBD -6398 (IL 09/I4) <br />BURNETT COUNTY <br />ZONING <br />