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Crony
<br /> 'x;` Industry Services Division /3r. .. < Yf
<br /> rId, D 1400 E Washington Ave S-r'n'Punt No 1' no 1n I llsd a b,Co.1
<br /> S'P I-I P.O.Box 7162
<br /> Madison,WE 53707-7162
<br /> Sanitary Permit Application "`""be`
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<br /> In coldnn with SPS 38321(21,R'i, Adm.Code snbmis,ion aflhis loan m the appntpri:m gn, ental unit
<br /> `req II t be g n 1 t Nl . A,Ie (en dand tatat - IPOAlTP b tl It P 11A Ircv.fldliennukn nada,Ade...)
<br /> the D" lnun trfsafly d1rofs mIS Lrsnut int , npood no,he wad lir..wndun
<br /> pnpw,e,in n i—hacc oh we Pn...ry In,.,,. is ormont Slay. 3139A f./p�/rs U c r7d
<br /> I. Application lnformaltnn-Please Print All information
<br /> Propmy O,vnu,Nunn Ynmd d
<br /> ir !c Gt/< !c 3 _ 03A 5-a108 od .k CO
<br /> Palmy ovner',Mailing Adni sc Pnpenr fnnalina
<br /> Gob tVjm Sr Goa.Iat a
<br /> zip
<br /> City,smlc ("'d, Pbonc Nmnbcr
<br /> s roma
<br /> Mod rlpn to'J'" S37/S ftniale,„,e3
<br /> X11..T,pc of Boiling(chock all that apply) I of p T N, R /9— F n
<br /> ry �
<br /> lnr2Fumfly Dwelling-6umbernfll.vlmoms Z / SnWivaian Nnum
<br /> Hlock d
<br /> ❑Puhhl Connal""I-Du,unh O,e ❑ river
<br /> ❑Snn (T
<br /> e .mt1-DesclxUse CSnlNnmher ❑ A'illapcor
<br /> (/.4 F? f W,I—nof Sr—I1l
<br /> 111.Tape of term it: ((:heck ni one box on line A. Complrm line Bi otpprcabie) (} - - _ _ -_ _
<br /> NevS.,mm L1 I<epla "mm�Sys¢m ❑TmmmenVflulding'fank aepmceincin Odle ❑ Od¢rplodifwtinn to lizivng System(eaPlain)
<br /> I5. ❑ Permit Renevnl ❑ I'annh Revision ❑Change or Plumber ❑Platin adt r In New List I'rcvione Pcnnil Nninb i and Dac Isnred
<br /> Bdre Expiation owner
<br /> I V.'I'v for of PO\\'I'S Svs[emlCom nnemlDeviec. (Check all that a Ir)
<br /> 10 Nnn-Presun-1 In C-und ❑ Pre-rued InGround ❑ At.Gn do ❑ N1,1amd 1 N in W unablesad ❑ swtmd<2d inor,aiwblc wd
<br /> ❑ Iloldin,'Ilink ❑Olh, Dispersal ced,,nncm lexVlaiN ❑Pill"Imonl Device te,hro
<br /> \'.itis crsal/IYcmnrent Area Information:
<br /> Ile,i�,flow(gpol Il :ti Sol Appliemion Rm Ygl»I) Dd...dAre..Rmpdad ill) D`I � 1Area Pmlwsal(,0 S_v,tem S1,,1Lnn
<br /> NA.Tank[no ('apnchyly Taal IMannf warGnllmn CIA—,Newranu ui.nneI...k,epstic or lI.Idn,crow '- Li-T4
<br /> ll aycLnmler
<br /> VII. Respaidhilit\Statement- I.tlonoissilad.a....in, re,...ibilis to ln .sllatio orae PONVI:SO., n the annshed pan..
<br /> Plan,ber s Nan,(Pruh Plumber's S,daarn NIPAIPR56umber Ilu,me¢Phon'Number
<br /> /2.4/6 Ne,/".f 1--.,�---+O moi` JoLfSS'/ /J=SZL- Y/5">
<br /> PImnKn,Add- ISua City,Sale,Zip Cade)
<br /> )77,l F/ 3S GdtSsY.� Ge%1 ,rrYS97
<br /> VIII.Cunity e arunent Use Only
<br /> Approved 111 D., PemoIl,,� Damh...li j I„uing Agem S,aanre
<br /> ❑ owner Given Rev,on for Deni..I ✓J-UU
<br /> 1\.Conditions oCApprosallReaeons for Disapproval
<br /> D MOVE nn
<br /> las”1--ptem in...far teeg msW.umma m mo Cnvmy unry un P^Per nm le„conn x ofroe,�nyT
<br /> U16'I 16 2013 IUJ
<br /> SILD x398(R0313) BURNETT COUNTY
<br /> ZONING
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