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- hK)D }ty Services Divi" <br />• 1400 E Wad ioginn Ave <br />\ �� P.O. Box 7162 <br />1/ Madison, WI 53707-7162 <br />Sanitary Permit Application <br />In WCOHIecee v4M SPS 38321(21 Wig. Adm. Cade, sAbmi=jW Of dm fwn to the appropriate govamneatsi crit <br />;s FW tD *bWM9 a sWWWY panut Now Application facets for stateowned POWTS are submitted b <br />@cc Depara of S":'y and n'*-Otmt Sc vi Persaoat ir>dor=WM yon provide may be need for <br />wndy <br />Duposm in acroordarcee v,�b the u.i- y Izw s. 15 M(JILMI Stals. <br />1. n� - Pkaae Print AN Inforsation <br />—UVCFXY owns -S Name <br />PMPCFtY OUNDW$ Mailing Address <br />20'105- )'0 9J) <br />City, State Zip Code PhoOe Number <br />wE�sT�/Z (� 5y8'93 <br />IL Type of Down (Check an that :1Ndy) La # <br />�1 or Fmmly Do suing-NumberofBedraoms Z <br />0 PublirACOmme,-W - Dercxbe Use Bock g <br />❑ State Owned - Deo Use CSM Namba <br />IIL Type of Pasty (Creek only one hoz an ere A csspIkMe Ise B if appieaile) <br />A. 0 New Sym <br />�1 SYS ❑ T� Tact Replacemat 0,1y <br />B' 0 Road R...W 0 Plrimit Revision 0 Cbangc O fMmbaBefore EVktin Townwer <br />st Tnr m Newm <br />6uKAI <br />-kKy PtmcB Numbs (to be ftllod in by Co.) <br />�D 0>1-i I l� <br />%%4rItCI = 67 -a/1 -.1 -y0 -JS - <br />.2 y- y 0a - 000 o i/600 <br />Pared# 07- 01 z- <br />o1 - 0 00 - Ui�aov <br />rngx y location <br />Govt.. Lot <br />AfE�- <br />prc,e <br />T_(ZN; R ' E <br />0 city of <br />0 Village of <br />XTovn Of �ici NX�1% <br />0 Odur Modification tO B dglmg System (espiam) <br />/J Y <br />W Nan-Ptesstriaod ko-t,rocsai 0 Pressurized in-('rO 0 At Dade 0 MMW > 24 in. cf a Wd 0 MMMd <24 is Of suifble swl <br />0 liddingTWk 0OtherDisposalp�mcpiain) FELT�t� C11.1JIsT�l2- 0 hftmMDM Device(e�lain) <br />V. DiMDera f/Treatnumf A— t-- -- - <br />300 65- 7 <br />rami[ Iu& cup -4 i <br />Cellons <br />Taokt <br />VIL <br />Plumber's Name (Pros) <br />CaRv � .��ck.So�1 <br />TOW <br />Gallons UnAs c <br />'a U <br />S <br />7.5d / wC <br />for iia" of the PORTS alas., ea tie atackd Ptk M <br />me"�tr &&roes Phone Nrm <br />S z4 3341 <br />Gt1-I 4 gra <br />APP>Ned 0 DkVpm d Ptrmit Fee D Date haLied p� Dung Agw Si o <br />Owner Given Reason for Deme) <br />CL Cel of APPS for Disappmai <br />Al <br />n1donfimmkto <br />SBD -6399 (R- x/14) � I I NOV 3 0 2018 <br />+� BURNETT COUNTY <br />700 nin <br />