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.6‘53:".914-4* <br /> y��a+�_�� <br /> Industry Services Division County • <br /> 1 f4�t 1400 E Washington Ave )Ufz�il <br /> ?i \$ l , P.O.Box 7162 Spy Permit Number(to be filled;n by Co.) <br /> _ ` $ W133)07-7162 l�s� 2`es <br /> �..,u, Cir--2,0 -20.1.,‘'3/yaz <br /> Sanitary Permit Application),Wis. s umber <br /> in accordance with SPS 383.21(2Adm.Code,submission of this form to the apprepriate govunm ntal unit : i'T <br /> is required <br /> Deo or tobtainingoa sy permit Note:Application forms for state-awned POWfS we submitted to Project Address(if ditfetent than mailing&Mom) <br /> theSafety and Professional Services.Pasonal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,& 15.04(lxm),Stats. R0 <br /> 1. A Ndleation Information-Please Print AU Informationf-t/V't {.-fy T/�(N • <br /> Property owner's plume Parcel# c 7-oiq- 2-3g-i ---073-S <br /> ISL ANI sle .,N,v-roa <br /> Property Owner's Mailing Address 5- vol- 012.00D �s� <br /> .-p. Q.. K i zz <br /> Property Location <br /> Govt Lot 7 <br /> City,State Zip Code Phone Number - <br /> _ 11., Section a' <br /> IL Type of Badding(cheek all that apply) Lot# T 3� N; R / E or oink <br /> 3;41 or 2 Faintly Dwelling-Number of Bedrooms 3 Z._ Subdivision Name <br /> Bloch# MA <br /> 0 Public/Commercial-Describe Use _. <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 4g7q OVillage of <br /> V2;ffJ /263 t7i.'1'owe of -A y�F 1.' 7-X <br /> M.Type of Perms (Chock only one box on line A. Complete line e B d appiitable) / ` <br /> A New System 0 <br /> AReplsoeammt System ❑Treatmat/Holding Tank Replacement Only 0 Other Modification to Existing System(etrpiria) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber I 0 Penult Transfer to New List Previous Permit Number and Dose lasered <br /> Before Expiration <br /> Owner <br /> l IV.Type of POWTS 5 (Cheek(Cheall that apply) <br /> ANO°' ed In-Ground 0 Pressurized In-Ground 0 At Grade 0 Mound>24 is of suable soil 0 Mound<24 is(Imitable sod <br /> 0 Holding Tank 1.Other Dispersal Component(explain) Fl LTE fj ,Prctnetment Device(eacplain) C MAT <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application ) Dispersal Ana Requited(sf) Dispersal Area rim System! Levant's <br /> 4/50 Z0 Z6Z) 4/12 <br /> —55 .51 <br /> VL Task Ina Capacity in Total #of Mamifactu er "- <br /> Gallons Gallons Units o <br /> New Tana; Existing Tastes err 2 U 1Q $ <br /> Sepik or Eapllieg Talc 4 U 'ch.' oro W CS, <br /> a / <br /> 1,coo i,000 , %wtEs <br /> Plumber's wnbar <br /> ILeI,die fid. 4. -t / '' fir�BaBoa date POWTS shown on ate attached plana, <br /> AEIMPII&Number Business Phone Number <br /> L'OfzY -TRKsoA1 ;�j 52-4 33 ' 7/ flab-fThy <br /> Plumber's Address(Street City,State,Zip Code) <br /> 930L .K BRC (RA., w isTIEF 13 8q <br /> VIII C sMy/Depertsseat Use Only <br /> Permit Fee Date <br /> APPro1ed ❑DisapprvvodLS;_. :, <br /> 0 Owner Given Reason for Denial $3�� /in /?,p, <br /> IX.Conditions of Approve Ulteaaaas for Disapproval <br /> -m ECEI V E 1) <br /> mem te t�be the wawa nod sar.tt sour OCT 2 2 2020 <br /> Cir�as not ten nosh nor:11 Cadre <br /> BURNETT COUNTY <br /> ZONING <br /> 8(8 08/14) <br />