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��r�K lkf <br /> Industry MmIces Vivision County <br /> Madison,WI 53707 <br /> 1400 E Washinigton Ave rT <br /> P.O.Box 7162 Sanitary Permit'Nwbc, <br /> -7162 (to be filled in byCo.} <br /> 5AN-6-2,51 <br /> -init Application <br /> SanitarY Pei. $tate Transaction Nurnn <br /> In accordarice with SpS 3831)(2),Wis.Adm.Cade,submission of this forma to the appropriate govemmental unit <br /> is required prior to obtaining a Sanitary permit.Note:Application farms far sMOwned po , submitted to Project Addi:vssffdiff��9=1�111ingadd,�,,) <br /> the Department Of Safety and Professional Smvtm pawl f, - VVTSM <br /> in accordance with the Privacy I'mati -On You Provide may be used for secondary <br /> -L-,-SL 15 wKini Starts. <br /> Inforwatian-pi-se Print Ail 1118 (1;4Al <br /> -Y Owner's NameF) <br /> I?Lts-q,--LL- QfQ130M Pat�# o 1-0 1 Z--z--—190-k5-�zl?-2- <br /> 1 111`iV ulvfw-s Mailing Address 0 2--000, 01 elo&)-4 <br /> 2--7-q 30 V, POPVT L-4)<Z 1:?L), Property 1-mation <br /> City,Strztz Govt.Lt <br /> Tzpcl�d-- Phone Number <br /> w q5sTeoez, A5 N w� Section 2-9 <br /> IL I ypeofBailding(Check all t—fi2t2p,Ity) rrcle <br /> Lot�# T '/0 N, R /9 <br /> X ler2i�arnilyD%imiling-Nunib�ofgedrwms E <br /> Ai A) Subdivision mine <br /> 0 city of <br /> State Owned-Describe Use -CSM,—Number 0 Village of <br /> ,57 To.of <br /> III. type of Perisait- (Check only owe uUm 00 IM A. Camps---' -.. -r P i X <br /> A. New System, rl RcplaoementSystena El Treatment/Holding Tank Rep only El Other Modification to Existing System(expWn) <br /> B* 0 Permit Rei-wnl 0 Permit Revision Change of Plumb, n) <br /> efore Expua6rin Permit Transfer-w N,, —rICVfUUS Permit Number and Date Issued <br /> Omer <br /> IV.T Of PO S S stemJCirel alert ace; 'Check A this.t I ap&) <br /> pressurized I-Ground 0 Pressurized 11 At-Grade 11 Mound-124 in.of suitable 500 11 Mound<24 in.of- ----------- <br /> Holding Tank 11 tither DispersW Component(eplam)_ D Pretreatment Device(explain suitable soil <br /> V.OisPeir"Urr-twent Area In tion: <br /> - <br /> Design Flow(8pti} Design Soil Applicmion RaIc(Vdsf) Dispersal Am A f) <br /> 150 o. 7 Al '117Pirtipos-d(sf) NIACMIalp''Idton <br /> -q.-Tank�Ifb 4ffa�p-ty in 3!:1 et) <br /> of <br /> Gallons Gallons Units Manufaeitffer <br /> New Tanks <br /> Tm*s <br /> AR <br /> vs ur iz <br /> r <br /> W.P-peasibility Statement-1,the Aw, <br /> W12fiza of the PoWrsh,,, <br /> Plumber' gut on the attached}clans, <br /> e0P,Y �T,34-,AK-SOAI MIMUM&Nmbe, Business Phone Number <br /> D'lrm .... .. .city;State,zip Co 5.2.q 334 <br /> f Gt-'X <br /> Vul.Conn rtmwt use ofil, <br /> roved Q Disapproved Permit Fee Date gent <br /> El Owner Given Reazan for n-;-i <br /> M U08ditions of ApprovaMe,,Olas for DisVprava-I <br /> APPROVED <br /> Aafth ft pw, I. in It EOW <br /> SBD-6398(R.0g/14) D <br /> NOV 14 2019 <br /> Burnett County <br /> Land Services Department <br /> .......... <br />