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County Industry <br /> } Industry Set-.ices Division <br /> `i ' ��, f 1400 L Washington Ave � rJ��E <br /> { P.U.Box 7162 Sanitary Permit Number(to be fillets in by Ct^-r i <br /> Madison.Wl 5 707--7162 <br /> i <br /> Sanitary <br /> y Permit Application t suite rmtL,acttQn I�ttmber <br /> In accordance with SPS 383 (2). f this form to the appropriate governmental unit,` !� <br /> f is mquire3 prism to nbtaining it sa niut y permit NtAc.Application faxmS for state-owns!POW I S art submitted m Project Address(if different than maiUng address) <br /> ! the Department of Safety and Professional Services.Nctscmai information you provide may be used for secondary { <br /> Purposes in accordance with the Prtvac�' eu•s 15 04(i m),Sets. Z 7>IiL,G( 5Aia LAKE Rp• i <br /> L Applicadon Information-Please Print All Information <br /> +�Pntivrty(hwer'sName —� Parcel# C, T-( tL� Z-�l <br /> J �1-4 CJC�j <br /> Property Amer':Mailing Address Property <br /> _ t=„t.Lot <br /> f~Cit%,Staw 1 Zip code —TP!tone Number !_ �11 _!, section `' <br /> iree ortc <br /> P,.T'V��i T►I.__._ v —'��441 �� 5 > "'�W Z 7 .I.- � <br /> ll,"I3 pc of Building(cheek all that apply) },__ _ _ <br /> trr2FwnilvDvNthing-hnrrtrrofL;ciri'�:ns 1 SubdictsionName <br /> ❑PuHieCanmercial-Describ; Cu_ Cttro'of <br /> 1 <br /> 4:wte Chvned-fksenbe t?se_-- <br /> CSSMM Number--- l ViHaxeof---.----------- <br /> y� Town of L�5 <br /> I11.'1•ype of Permit: (Check only one box on lane A. Complete titre B if appiieable) <br /> A. ❑Nev,System 0 Rep!tcenttni 5pstern ❑1`reatmerttiHokding'I'tmk#tc tlaectnettt Choy �t?tlter Modifieation to Existing Systct,ie Kpluln; <br /> ! ADD;O& <br /> er an3 a Iss ! <br /> R. (]Permit Rertcvaal ©Permit R<rvistatt Change of Plumber ©Pertttit TraI to New List Previous Permit Numb uer± <br /> t t3efereEtigiraticn j C3tti7ter yZ-1`-7 7-tq oq_# 2-coq <br /> t.lVjype of POWI`%4t•ststn_1Component0evice: (Check all that apply) <br /> Non-rrea;tt In-Ground -3 Presiwnzed In-Ground ❑At-Gnxic ❑Mound>24 in of suimbic stiff Mound<24 in,of suitable soil <br /> tioid;ug Tank: Cl Chher Di;n-erstu Component i explain)_ _ — ©Pretreatment Deti ice(explain)__ t <br /> r.D-wersalfFinatment Area In formation-. —� _etialiorc <br /> Design Flow(gpd) I Dest;rt Soil Application Raxe(`apdsf) Dispersal Area Required(sf) Dspersal Area Proposed(SI) System Et } <br /> -, so <br /> VI."rank Ira€u C, city in Total ti of Manufr� Curer �— _7__.. <br /> i <br /> I — Ui lotts _ Gallons Units � � v � '-:1 � i <br /> � j <br /> 11r�,>r� t�ce C�lc i.�,c� I I s n�v'�._.__� T x-, <br /> � ,:encl.ert„r, �1�Gt4e� T)VOL--TKAMram -t-- ---f---ram{ <br /> l �'ti.Responsibility Ststsment- (,the aadersigaett m ma ty for iastattatioa at the POµ-f5 shown on the attached piamr _ t <br /> j Pi,mber's Name(Print)T �{ Piuts S Si rc 'vtPl+tVRdi tvumher k3usiness Pttotie/?ice:bcr <br /> it �'C�t`� _Jr- TWct st '�,f F 5.2" .?..�` <br /> Plumdber';JAddress(Street,Chitty,State,Zip�t/:culre�j h i <br /> [?f"CLt!'`..i'-r,..+'It (i 1:'�' <br /> Fill.C'OuntviDe rtmertt 1,50 <br /> ` 1,pproved 1 L DisapRrov-ei <br /> YcmJt l ox Clete IwueS hcwng Agent Sigtultitre <br /> r i <br /> �^ '. �Ou°rser Gt4rn fteaSd;t the lyenixl � 3 7J, — -r/• Z/ 1 �_l.fJ�_. --.______..___� <br /> I:Y.Conditions of Approval/Reasons for(Disapproval <br /> 4 4 <br /> _.___..___..._...r <br /> !ouch to eotop lute plea&rot•the syttew aad sab,uk to the Cow o only as paper txx seas than ft <br /> SBU-6398(R.08/14) APR 2 9 2021 <br /> Burnett County <br /> Land Services Department <br />