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"ii (ounly 6� <br /> "D' <br /> �s Industry Services Division <br /> /�,'ffp Aunt �Qr 1400E Washington Ave Sanitary Pevnit Nmnbeglo!E <br /> be filled in by CoJ <br /> S P+: f•1 P.O. Box 7162 C' 7�3f- <br /> S Madison,WI 53707-7162 / I IC 7 <br /> \y*^"b Swra Tnn.aaion vm`nner <br /> Sanitary Permit Application <br /> Inscc d onSYS383. 1( ) Wa,Ad Code, b fth f t the'Ppmpnme goveme gel t <br /> is rcqu'reAI r ubmifg sanitvry Vemri 'vole Appfcatm1 frasiro 'in <br /> ,POW'I S aresub ltdl PmledAdd (ifdifhzenuhan made,addreesl <br /> the Uepamnent ofsafely vnd I'roPssional Snrnes_ Persoval informnnon yon provide maybe used for secori 0'/ ' L,//y <a n e <br /> ccordvvice wiN thePwacv Low,s.15 01 Se¢ <br /> lu ASecllcatiun Information-Ylevsc frontin Information _ <br /> Pmlxny Owner's Name oa.ind03d-1- 4/_x6-36- Y oS <br /> ll,/arr�h l�051 e.. 000—ei9000 <br /> Property Owners blaaing Address rmperty fooannn <br /> e3ssI / „3 �. r �n.t.fpt_ <br /> cry,State zips i" Phone Number fW Y•, S� °1, section <br /> qq �� // ( roleon,) <br /> /l �e Vb/� V" its. SS�dN T 1/ N'. it /41 Eo® <br /> IL Type of RuildlnR(check all thn[apply) LorM <br /> (� Subdivision Name <br /> ®1 at'_Family Owel ling-Number of Rohnonu <br /> Rluck4 <br /> ❑Pettre Comm,ireud-Descrto,Use ❑Ciry or <br /> CSMNori ❑ Village A <br /> ❑Smm OwneA-Desmbe Use �� � � 'q/// ®Town of 1/JS <br /> III.Type of Permit (Check only one box on line A. Complete line 6 if applicable) LGV <br /> A' New Sysmm E Rylacemwt Sysenn ❑ TrcnnnenNloldinS Tank Replacement Only ❑ Other Modifmahov to E.oc-S System(explainl <br /> lk ❑ Panni,Rennval E Permit Revision ❑ Chen,of Plumber ❑r—o'Trarvcfa to New <br /> fatY_1one I'ennit N k a.and Dare Issued <br /> Rcfor,6xpimdon �per <br /> IV.Tv c of POSVTS Sstem/Com -----Dcviee: (Check v11 that o t tiv) <br /> Fon-P—razed a Grouml [I Pmssm'ived In-Ground ❑ Al-Grade ❑ Mound>24 irvot ernable coil E Mound CS in,efsuitable .it <br /> ❑ Ilalding Tank ❑Other Dislmoal Compoent(explain) ❑Prenrnllnent Ucvice(ezpinilq <br /> V.Dix er,.I/l eatment Arco hRormadon: <br /> Desiym Flo,(epd) Wia,a Soil Applicmion Rare(5Peb0 Disrersal Ama Required(s0 Dispeaval Ar©PmposM(s0 System Elcvahon <br /> 300 . -7 vo( 9 -Y 11 93. 0 <br /> VI.Tank Info Capacity in Nuid kof Manulucwrer <br /> Gallon Callon Units U 2 _ <br /> wTaoks P—,unTanks <br /> Sepr <br /> e ar umainp Ann epo /osb In Fr/�^^-7•�' X <br /> nosh,ebemher <br /> VII.Responsibility Statement- 1.the undersi;med,assume respnnsibilin,for installation or the POIVI'Sshmm on the attached of . <br /> Plumber's Name(Pon,) Plumber's Signalure MP/MrRS Number uusineac Phone Number <br /> 1_ <br /> Hookers Address(Sheep City,State,Lip Code) <br /> d 77Gd _ 3S w.e6s{„ w Sva9S <br /> VIII.Coon o artment Usc Only <br /> Permit PeeDinelssud <br /> I] Issuing Agent Signuan'e <br /> Approved .net to ve <br /> ❑ Owver Giv Reason for Denial <br /> I%.Conditions of Approval/Reasons for Disapproval <br /> R 1 rr <br /> rr <br /> a, <br /> Roach o—der plans for rhnemaad mono to an Corny oak onpaperars <br /> mlethanev Il.no-il !'� t �. 2oll <br /> , <br /> 0c,s-1— <br /> iL Ul. 1 _ Y <br /> BURNETT COUNTY <br /> SRD-6348(R0313) ZONING <br /> 1. <br />