Laserfiche WebLink
Conine <br /> a X�- Industry Services Division I?-,n a-7�' <br /> ;ji; p I .:s 1400 E Washington Ave Nanny Pam[Nanlw-Ra be Inca in by Co.1 <br /> ','y SIT"', <br /> P ;., Y1 P.O. Box 7162 <br /> Sc�r��313 <br /> Madison.WI 53707-7162 <br /> Sanitary Permit Application SaneTUr ion Nomper <br /> Iv acmrelance with SPS 38321(2,W is.Adm.Codesubinisslon variant form to the appropriate governmental unit <br /> reyulred poor to obmivNgamnimrypennit Note.Application turns forsmm,rovial POW IS am submitted to Pjwt Addmss(ildilicrent[han mvilingaddresal <br /> me orommenrorsafen and pa,res,ional servies. Personal adormation you provide maybe used for secondary /d I a a1 Co /7d Z <br /> accordance with the Pdvacv Law,s. 15.0Stan <br /> la se 1111(m),Application Information-Please Print All Information <br /> Pre"Owner's Name - Pare( I_SoS. on3 <br /> Alc/..d L< p Sv- _ 019000 <br /> Pmptary Owner's Mailing Address Pmceny Lusatian <br /> 01/35 <a li Fa r.tc ft tit Govt.Lot 3 <br /> City,Sure zip Code Phona Number y b, Section AA <br /> /riplJ ^ ^ SY7 S GU- 7d°- 3/89 <br /> (cast, a,) <br /> P.Tv pe of political,(check all that apply) Lot# T_ N1 R /9 Eor® <br /> tcv or?family Dwelling-Numhro CBulroona Subdivision Name <br /> Block# <br /> D P bor Commercial-Describe Uac <br /> ❑City of <br /> DStamOwnal-D�,uhaUse CSMNumbtt ❑ Villagcof <br /> IrwinofT../m Oaf <br /> 111.Type of Permit: (Check only one box an line A. Complete line It if applicable) <br /> A' El New Sysan 5Rm <br /> eplcccan 5"". D Trcmmen0l Iodine Tank Replacement Only D Other hlomfirmion to Exisn'ng System(-,[a.) <br /> it. DPermit Renewal 11Ponca Rev Sion 0CM1angcof Plmnber ❑Penult Tmtssfeno New List Pruencon Penni[Nmai and Live Issued <br /> Before Espirito Owner <br /> iv.'ry a of POWTS S stem/Com omot/Device: (Check all that a Iv) <br /> D Non-PhaScal7ed In-Ground D Presumed lo-Ground D At-Grade D Moral,24m of .,,able mil D Mound124in ofauitable mil <br /> Holdm,Tank D Other Dispersal Component(exPImn D Pretreatment lkvice(explain( <br /> V.Dis ersalfrreatmem,Arco Information: <br /> Dasign Flow(PPB) Design Soil Appbcmion RaggPdst) Di, rel AAr Required(st) Dr,ar,al Arca Isr.i 1st) System Elevation <br /> VI.9'ank Info COPa d,in Total #of Manufacturer <br /> GvllovsGallon, Flu r, jNi Hew Tartsst6,gTaaka <br /> le <br /> seer or nnldore Tank )SOU JroO Wates�a <br /> oro'n Clumbu - <br /> N'II.Resp urnihllitrStatement- 1,the a pler,nock mesa me re,,amobilirc for installation of the PORTS ahaxn an the attached plans. <br /> Plambc,s Nauru(Pun) Pbtmber's Si,mr, MPIMPRS Number 13uaivus PM1onc Number <br /> /2 cele /+- le,.J 7i.�i r�GG <br /> Plumber's Address(Street it a ,Stam.Zip Code) - <br /> ,L776o F/ r 3-5— �f/1-J/"L / GU1 '?1%3 <br /> VIII.County/Department Use Only <br /> 9Appmved 0Donpproerd permitl'ee Da Is Issuing Agent Signature <br /> 0a {� <br /> ❑ Owner Given Reason firz Denial 378 �/� 4--1 <br /> IX.Conditions of Approval/Rcawln for Disapproval <br /> A s?' kiiHT /.t .Hor2 cACCw.nn—✓s 7F <br /> lips a< �� 1)15Pati gy 0UIs. p EC HISS <br /> Attach to complete plane for the—ran and car—to the Coun_ mayon paper not less thao8 trz a"in <br /> vM1aiu i SEP 4 2014 <br /> SBD.6348(R0313) BURNETT COUNTY <br /> ZONING <br />