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pf"aTV[yJ 7 <br /> z� L Safety and Buildings Division County &,C,�t///- <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be fined in by Cc) <br /> 'Sp Madison,WI 53707-7162 I <br /> 11 <br /> Sanitary Permit Application State Transaction\N/umbe S <br /> In accordance with SPS 38321(2),Wi,Adm.Cade,submission of this form to the appropriate governmental unit � 7 e`J <br /> is required prior to obtaining a sanitary permit Note:Application forme for state-owned POWTS are submitted to project Addras(if different than mailing address) <br /> the Departmentef Safetyand Professional Servies, PersonWinformationvoupwvldemaybeusedfarsecondars Ka/CCwooe/ <br /> puffosex in accordance with y the Privacy Law,s. 15.64 1 lats <br /> m,S . <br /> 1. Application Information-Please Print All Information 20837 <br /> Property owners/N{m /�. Pared a 07-03 Y-z -3-7— "Z/-9 <br /> / /�.N ".4 Is (,[113 OJ-0 DY- 0Z-700 <br /> Property Owner's Mailing Address Property Location <br /> 51 3 /Z f5 V L `-T Govt.Lot_� <br /> City,Stale Zip Code Phone Number C' C, Section Z <br /> ` :' �ti' Sr07s reF,learn) <br /> 11.Type offulding (check all that apply) Lot T�N; R� mW <br /> 41m2fvail}Dwel1ing-Numberof Redroonu 2 3 Subdivision Name <br /> Block 9 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ID State Owned-D.edhe U. CSM Number ❑Village of <br /> V 1 10 9 J2 Town a"77�— etc / <br /> 111.'fy pe of Perm it: (Check only o me be s on It n e A. Complete lin c B if a ppl icable) <br /> A' ❑ News'ano FReplacement System ❑Trewarcntdiolding Tank Replacement Ory 13 Coo,'Modification to Existing b5stem(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumbic, ❑Permit Transfer to New List Previous Permit Number arm Date Issued <br /> Before Expiration (Tuner <br /> R'.Tv a of POR"I'S System/Com onen[/Ueviee: Cheek all theta Iv <br /> ❑Non-Prensuric d le-Ground ❑Pic....ued In-Ground ❑At-Grade ❑Mound'24 in.efsuitable seal ❑Nlound<N in.of suitable sail <br /> Wtloldinglank ❑Othtt Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Uis ersal/freatm eat Area Information: <br /> Design Flow(pit) Design Sail Applieation liate(gpdsl) Dispersal Arca Required(s0 Dispersal Area Proposed(s6 System Eleve(in <br /> 300 — — — <br /> VI.Tauklnfo Capacity in Total 4 o Manufe,tumr <br /> Gallm s Datums Units <br /> New Tuts Existing Tank _ U `-' - _ - <br /> dy-/U <br /> Septic ar aldingT d00 / S thy,/ !- <br /> 1)wu'ChamMr <br /> \'I1.Responsibility Statement- [,the underogned.nxsume r-ponsibililc for insmllation of the plan, <br /> Pber's Name(Print) Plumber's SomeoneNIP, IPR 'umbar Business Phone Number <br /> a�c�kc a S;Ns zzz87z 7/S- 9i- 55e <br /> Plu hers Address(Suret City,Stem,7.1p Calc) - <br /> Zlo � / 0 ' i, -ucK µ 53 <br /> \'I[ ountv/Ue mrtment Ilse 0.1, <br /> ,proved ❑ Ilisappmvcd gPermit Fee Date Issued Issuing A� S' arere <br /> ❑Owner Given Reason far lXnial 3 7�� 171v. i3 <br /> IN.Conditions of ApprovallReasons for Disapproval <br /> TUN2013 <br /> C Odd <br /> .s6oz- in7i-- r(< . t'/99) <br /> 17 <br /> Amchmmmplere plain forn he..vete-dsubmiun the Coon..only on papernot lnnhmgtRall M1 - re <br /> BURNETT COUNTY <br /> SBD-6393 It, 1]/[I) ZONING <br />