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"fre <br /> Industry Services Division <br /> ! T4c� 1400 E W Ave Y 6 biil E-77 <br /> I!'N\!r r, P.o.Box 7162 y Permit Number(tod Co <br /> Madison,WI 53707 7162 SPM- )9.--//5 � 7 <br /> Sanitary Permit Application T' '°°"'umber <br /> In accordance with SPS 38321(2),Wis.Adm Code,submission of this form to the �✓1 <br /> < <br /> is required Prior to obtaining a sanitary permit No Application firms for slasowned POWTS are submitted to P Add <br /> uess(ifd Ido addtea)theSafety and Professional Sari=Personal <br /> ed'onttaRion you provide may be used Lor seoopdary <br /> puqxoes in accordance with the Privacy,Law,s.15-04(l)(at);Snits 81 n T 8 <br /> In -rime Print AR I.ba ation f {Rye v 7 <br /> Property s Ike •7 <br /> Parana 6 _ Ota- z '�[� <br /> - -/s_/�•a- <br /> 2 - <br /> Property ii , IlitieL /5-7_04.,t5-__ 03;eed� � <br /> da� <br /> s Mailing Address Property LOCStiOn <br /> [a&70.7 FLOC 'DR <br /> City,sate - Govt tat - <br /> Zip Phone Number - 'A, - % sazion / <br /> DM13UgY, (AIS 5/556 !� leiscle <br /> II.Type of Ba .g(dwelt all tient appy) Lot/ T 70 N; �� Ear w <br /> � <br /> Irl or2Bondy Dwelling-Number ofBedrooms 3 i'' Subdivision Name <br /> Block 301/'tLA/4E <br /> 0 Pubiio .ential-Dr:sc 1pe use - <br /> 0 City of <br /> 0 State Owned-Describe use CSM Number 0 Village of <br /> 14 Town of j,/}CAS1/y <br /> III.Type°fliers& Maack say one box ea lie A. CempieLe Sae B if appiiie>bie) <br /> A* )4 New System 0 Replacement System 0 T <br /> sT>nk Replacement Only ❑Other Modification to Existing System(explain) <br /> aPe- 0 mit Rhexes 0 Permit Revision 0 Chime of Member 0 Permit Transta-to Near List Previous Permit Ni rber and Dale hosed <br /> Before Expiration owner <br /> IV.Type sof FOWLS (Clack an that apply) <br /> XNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mand>24 it(Walkable sal 0 Mound<u in.ofariable sod <br /> 0 Raiding Tank 0 Other Dispersal Campwnruc(ems) 0 Pastrearmast Device(explrin) <br /> V.Dimponalrfresiboont Area bdanastia_ <br /> Dense EWE/(Std) Design Sod Application Ra1dF ) Disposal Area Requited(at) Dispersal Area Purposed(s}) *dem Elevation i <br /> ilt_se) 'e+ 7 1 02. 66-0 Cis : a ,' g�.sn <br /> VL Took Info min Total /of - <br /> Gallons Units o <br /> w <br /> New Tasks Exist*Tanks 1 1 m is Lh 1 <br /> a. <br /> 4 000 ,1,006 ' i &'JiES <br /> m aach...lw- <br /> VII. <br /> i Plumber's Stat e.rrmt-I,tie ,assume re pea, ,kr k.aB.' dtaa FOWL S ai m es the sambas plena <br /> L o�Y=� KSoipi..,ba-s7ere_______Name(Print) <br /> Business Pimm Number <br /> Plumber's Adducess 24 33/ 71,5 64,6' it <br /> ( City, <br /> 9306. . peK 6,?ct JeA, wg6sr- w2 ...91R3 <br /> Vm.1G.styll Use Only <br /> cAppaored I 0 Disappeared Pols Fee Date Issued Inning Asst ,_ <br /> 0OvmQGiven Reasonfor Deaid 1 s 37,. --7^/7-, <br /> IR.Calilda.s.# for - — — <br /> AuerN to eaplese plows far au spins and mewit is Or C'omr r ally es, err art les Om I Yr i i l iarko IE c E il v E 0 <br /> SBD-6398(R.08/14) JUL 17 2019IJ <br /> BURNETT COUNTY <br /> ZONING <br />