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" IrltJstry Sues Divbiot <br /> - 1400 E WasEl 7162 Ave <br /> P.O.Banc 7162 Saab"Permit Number(to be Med in by Co.) <br /> Madison,lM 53707-7162 A — — <br /> _1� <br /> ./C <br /> Sanitary Permit Application State TransactionNmnber <br /> 1n a with SPS 383.21(2),Wis.Ad.n Code,submission ofthis farm to the Muoprigft g m mnnt unit <br /> is t Prior to obtarranga sanitay p+ Note Ap�fti farms far sfa�owned pow Ts are submitted to <br /> the Department of safely and Piarcssiooal Servia;s_ Personal mfarmatmn you provide may be used for secondary Prt jeer Aadz=(If ddkfcnt dM mat7m9 ads) <br /> PUIP ;n acoanbnm with the Law,s.15. 1 m Stilts 0410 /-to ye/'5 Z,4) <br /> L Aklopficaffen Informs#ien—PltmsePria#AnInfermatiou .S G/ 5 <br /> Property owaer's Name Paced# 07-o2 y-a -3q- /y-1,2-5 <br /> t1. ki' 0-5- -Cby-D/3e�' i5$B5 <br /> Property Owner's Marling Add ftoperly Location <br /> �_ 6,IX z Rcl GovL Lot <br /> city,state Zip Code Phone Nwuber ys 5k section <br /> 1�.�s ) k� mot ( , <br /> T� N R�� E at� <br /> IL Type of Building(creek A that apply) P � � dje ✓`' <br /> I or 2 Famfly Dwelling-Number of Bedrooms .3 � � � _/ Subdivision Name <br /> ❑Public/Commen;ial-Ocsmbe Use Block t# <br /> ❑State Owned-Describe Use ❑City of <br /> CSM Number ❑Y7lagc of <br /> rte Town of 1`U, A <br /> IIE_ �o�f�P�ermit: (G'�Crl�cto one box on lice A. Con Um IS da <br /> DN= <br /> A. , System Replacmcut Systm ❑TmMMWIMft Tads Re w==Onty ❑Other Mod on to Existing System(atplam) <br /> g ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Traasfa Io New List Previous Permit Number and Date Issued <br /> Bef xe Expiration Pbmnber owner <br /> IV.Type of POWTS S em/Co gMvice: Check all thatapply) <br /> Non-Prm ai m-Ground ❑Pmwui wd kWAowaI ❑At-Graff ❑Mmmd>24 m-of smtabIe suit ❑Mound<24"sr.of=Iabk sort <br /> TI Holdmg Tam: ❑Other Dispersal Component(cqd m) ❑Prat Device(explain) <br /> Y_ rea#men#Area Information <br /> Design Flow(gpd) Design Sol Application Dnpc sat Area Required(so D4asal Anew Proposed tart} S`ystxan Elevation <br /> r-/50 ) 0, 7 <br /> VI.Tank Info Capacity in <br /> o <br /> C>ellars Turd #of 0 Mann xaa m R <br /> W 9 <br /> NeaTmda E�g Tants Gallons Units 2 L S <br /> e`CJ (n m c;O o- <br /> Sep&or 1-AI*Tamk � � l �,e � ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> VIL Responsibility Statement 1,the under,awe rcsponsibRity tar anstafttion of the POW7S sbawn on the atlacbed plans. <br /> PI ber's Name ) s Sigruoae MP/MPRS Number BusiocW Phone Nrm bar <br /> z". Vlt.6e�et IPM <br /> Plumber's Address(Street,city.Staff Zip Code) <br /> VIIT_C Use Owly <br /> �A ruvca ❑Dis proved Perms Fee DawAssqcdAgeaa <br /> ❑owner Given Reason fir Denial S 3 3 act 9 <br /> DL Conditions of ApprovnMessons for Disapproval <br /> APPROVED DI[E 0 [E 0 v IE <br /> ewe <br /> A�te�p�s�>k�����C•�tsrsNt��tles�.sta=tt- <br /> AUG 3 0 2019 <br /> SBD-63N(R03/14) <br /> Burnett County <br /> Land Services Department <br />