Laserfiche WebLink
Industry Services Division CountyLUrf\C�t <br /> 1400 E Washington Ave sanitary Permit Number 0p he filled in by Ca.) <br /> 1 <br /> P IYI P.O. Box 7162 W s sl S/od <br /> Madison,WI 53707-7162 '9 1119 <br /> Sanitary Permit Application Sam,TrransapetionNook, <br /> In rdance u uh SPS 383 21(2),Win.Adm.Code,sampiN an alias form ,,the dpi.....governmental unit <br /> raccoequired prior to obtaining a ssnitare, ament. Note:Application loons fur staleusmed PDN'IS me subminedm Project Address(if JiRcrcnt than mailing address) <br /> for D,panmem of 5alig and Pmfessiowl 8cnies. Persnwl informazion you pr..ide may be,cd for otMarr <br /> put,ove <br /> sin accordance with the Per a ,Low,s.15 wit him.Smu. <br /> 1. Application Information—Please print Ml lnformntian / <br /> Pfopeny Owners Name Parcel W rd <br /> Lu�F1,er �6;11t- 07-04Z-1oy-oo6-51 coc <br /> passivity(ma',Mailing Address Property Isneation <br /> R.rcct 1 n <br /> 115 �S l.ax4her �oirv} �. <br /> roof ].or If, <br /> City,State %ip Cnde Phone Number Is 'd, section 3y <br /> Gra,6sbur ,)\}L 5k{$yD T 38 N: R �`irmean, <br /> 11.Type of Bulldni(check all that apple) Lot d Eor t�\1 <br /> D 1 ort Family Dwelling—Number of Bednwms Subdivision Name <br /> block <br /> V,Pamir/commercial—lkscribe Use L"jjjirl'u� I. ❑cin ar <br /> ❑Sane Gored—Da.r,k Use CSM Humber ❑ Village.! /� <br /> ATowaof OC1 RU�Oivet^ <br /> III.Type of Permit (Check only one box on line A. Complete line B ifapplicahle) ,�/O <br /> A. 0Nes,System D Replacement System D lomparencllolding Tank Replxemcur Only rap,Other Modieeation m Esisir,System("'Itar) <br /> P,dcttT\ w 3Wo rJ.slidt gvK�tcw 9°I-Yt 1 nrpHn <br /> B. ❑Permit Renewal Ll Permit Revision D Change affirmation D Permit Transfer to New List Pream,Permit Norman ad Dae Issued <br /> Before Estimate, Owner <br /> 11'.1nine of PON7S System/Cum ....order ire: Check all that apply) <br /> 0Som-NessurimdP-Ground DVia...risadIn-Ground DAt-Grade ❑Mound>24inofsuitable soil ❑ Mound<2d in ofsamblcsoil <br /> radar,Tank D Other Dispersal Componrnt(explain) D Proletariat Doric,(e,dain) <br /> V.Dis emal Prem, end!Area Information: <br /> Design fl ow l gild) Design Soil Applicaion Ram(gpd,O Disporml Area Required lsD Dispersal Area Proposed(et) System Elesution <br /> 5333 IIA MA NA NA <br /> X1. Park]of. C.'ar"m T ii Manufacturer o <br /> Gallo, Guiana Grain, — g <br /> Septic or Holding ram, ,3000 VJ'e.0r - - - <br /> Es iag Chamber <br /> \'ll.Hesponsibilit, Statent 1.the nndrrsia c ssibilin co <br /> for installation of the PONTS thou on the ached plana. <br /> Plumber's Name(Print) u hr' ' 611'1MPR$Number Business Phone Number <br /> Da -lvn R -�Lwds n <br /> o7 oft, 71s-3yv -s5'33 <br /> Plamhr's Address(mvect,city,State,zip Code) <br /> Por3o* &�(o 0c, <br /> \'111.Can in t./Department la.se(Ink <br /> L)Approved Ll DisapprovedI'rrmit Fee Date Issued lssuin •ext Signutue <br /> P <br /> ❑Ounor Given Reason for Denial S�Zb ' 9/l//i3 <br /> 1\.Conditions of ApproraVReasnns for Uisapprovel ECEVEn� <br /> nn, <br /> SEP 4 2013 1 <br /> Attarb to mmplen plans for the.^nm and r.emWo the Coa _ mm%on taper nongt m.nanxtO a site <br /> BURNETT COUNTY <br /> SBD-6398(100313) ZONING <br />