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.Sasrrry�. County <br /> ,It \%; - Sa"and Buiklkx-ls Division of <br /> S!' B zs 201 W.Washington Ave.,P.O..7162 Seneary Permit Numberlmbe filled in by C°] <br /> .SP I Madman.WI 53707-7162 <br /> Sanitary Permit Application S..Tam i°°"ams , <br /> In ace nda a xIN SPS 353 21(2).W h_Adm.C°de,sudvisim of Mis fomn m Jc appopble g�mit <br /> is re9uinW pnwmot¢inilgaseneary pcmriL Np Apl f rmssesal-se%]M mesrAm. P jecl Address(ifdiRerenl tw mailing address) <br /> the D<pamn<nl of safety and Pmre netl Serie, eernnrl wrnnnmwn ym Pro de may be r far--dary <br /> Lr s1inattroNanccirilh Ja PrW I.nW.a.ITWllxm 5tea, lI <br /> A IicatianmPnt All <br /> PmpczPaned d <br /> ( <br /> r <br /> aN aa965tbYan <br /> Property U.ner's MaMailing Addr / pn p ,Location <br /> 2f�7� !f QY W/J GeL oI <br /> Cin. cmc 2y Code Phgc Nrvobv <br /> 62- 7-oygZ T N; RE.10 <br /> II.TYPC ofR iW ing(eheck all that."",) 1at9 <br /> IXlor_Family[Tvellirg-Number of BeMooms W Subdivision Namc <br /> Rw d 5 P� W a <br /> ❑PubliGCommcr<ial-DcacdM1c Usc <br /> ❑City of <br /> ❑smle oared-DarHl use CSM van, f <br /> VTe,. f_Ta� <br /> IILT,e.fPermit (Cheekonlyov<busonline A. Complem Bae Bifapplirable) ' _ <br /> A. ❑ N -sy,wrn I '�Repnttmem Syuern ❑Team nkiie,Tv R<pl. ussm Gnle ❑Ulan Mcdif donm—E<ius[!m,Sl em(e,Wn) <br /> B. ❑ P<mdt Removal ❑Pemrit Revision ❑chv .fPhmtnee ❑Pamin Tmrrenm New �vn°ia Permit NumUer aM Dalc Issuetl <br /> Berorc E,imlion Qrm <br /> IN'.Tv a of PO117S SvsteWCem onen0f iee: Cheek an that a 1 <br /> �rasion-PfcswiwilnGtauW ❑PresaaiIIdln Mr []Ater ❑Mwvd?2t in.ofsuitaMe soil ❑MouM<24 morsuieblc soil <br /> ❑ Holdn,,Tank ❑Olhcr Dvycrsai Compacr:t(eepnm) ❑Prnreamem UeOee('Warn) <br /> N. Dis erva Vrreatment Am Inforrnati°n: <br /> Desien Flosv(Epd) Desien Snit Ao Brawn Rgefgpds0 Dispervl Anes Repuimd(M Dispersal Ams Pmm <br /> ped(so System El.,m <br /> y5U 9oU 9 CYJ 95 2 <br /> NL Tanklnm Capadt.•in royal dnr Mawtamaa <br /> calf Galloia ups _ - _ <br /> Few Tmks Fiaiig Tanks u 2 <br /> 2J A 1C <br /> Se(aiear HONingTmk I �/� w <br /> pain6CTanber 4 1 � W <br /> It. Itespousibilil SIMement- Erhroodersrwnr .nmarrgnmbitiry fm:msa�rbe afim POW'15Je. oaM1utbcmd pnnr <br /> Plu rsN..,(Pr//im) Plumb<r MP/MS Number BuB..M.ne Number <br /> 0�q Pr PRS(95h 7/5 B66 70 <br /> Plum W's Addr (SmeL Ciry.Swe.Zip Cy�1 <br /> Z722U ,,;w <br /> 4m,ZS Kd WeLtlevW:'glfe f <br /> \"III.CountvMe artmml Use Onh <br /> AppmvA DDnsap vW Permit Re Ume lswM Iavin6 A�sn5i�aune <br /> ❑Oxner Given R<aon fon Denial <br /> IS.Conditions of A,pro,.Meanns for Disapproval <br /> �wb� n+errr/w:r 3/1'� uvci' c,.cr c�•s..L.vf, SYS, O.IC!/,�p[� D �II _LS� if I.5 <br /> ii c(oK, I�IL+J <br /> �tinms.m,a.n nam nrwa,rao-m anammhm uw t.�veary.a P.pe.nwl�tmaenr_.tI ae <br /> BURNETT COUNTY <br /> SBIM39S(R. 11/11) ZONING <br />