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k, V, Industry Services Division (j n✓n �*
<br /> 1/I�D`n" Ft 1400E Washington
<br /> 62 Ave Sm,iwry Pcnnll Nundurlm nc t11led 1n by Cor)
<br /> S" rl P.O.Box 7162
<br /> I k Madison.Wl 53707-7162
<br /> Sgne'I'mnnwtion Nmnncr
<br /> Sanitary Permit Application
<br /> m 'ned PO'th mtl t
<br /> ,nqt" 11 ono onte�ns; xadnry tart,- NOLL nPPru,r nlun,wl surto Iron rs nam t It I ,gym na,r.0 l-1 nr«mto-:l,,,,adhag ond�nl
<br /> tin peraddean of Salely ami proleldis-1 Sema'. Personal inlimroa o t Ynu pnrcidc may ba—11 for twcnmbrr A86 S8 //
<br /> w wses in acca thda,with do Privac laws. 15 M(1)(m).Smd. Bees t'A? 17,/
<br /> 1. d),iicntion Information-Plcmc Print All Information
<br /> guaranty 0aner's Nann Purtel a ai 40_!sr
<br /> I� 07-0/d' - oGI - O/ fi 00
<br /> /o, V<nmeh
<br /> Property Oxner's ba krig Address PmpenY Ldnauon
<br /> f00 G,.�rn N<r h{f ]"'✓L Govt.fm i
<br /> City.9me Lip Code Phone Number y i. Semon
<br /> dmle ore)
<br /> a r zle /+'k/✓ SSo 7d T 4o N; I\ 4S 1",m6)
<br /> 1L'fcpe of Building(eheek all that apply) Lto
<br /> Sidsh,vo t Nana.'
<br /> I m?14mily Dwelling-Numtnr of Bnlydnm. 3
<br /> Black a
<br /> ❑Pub&,Cmmnemial-Urscrihe Ilse ❑Cirvof
<br /> CS\I Number ❑ Village of
<br /> ❑State Ow,md-Iksenbe U+c ��q
<br /> Pr y5-7 PrTnwn of
<br /> II I.'1,,of Pe,aut: (Cheek only one hos on line A. Complete line B if applicable)
<br /> A, 0N...SYstum Ileplacennnt System ❑TremmenW holding'I'ark lhplacennnt 0oIY ❑Other Modification m lusting System lexPain)
<br /> 13. ❑ Pennh Ilcnuwal ❑ rennit HcvisinI ❑I have al Phmlls" ❑Pem,it rrnn far to New I-i Previous Permit Number mal[)ate In,ued
<br /> ner rc linnirntion owner
<br /> I\'."fv pe of PORTS 5rsteductm onentlDes'ice: (Check all that a, h')
<br /> RNon.rnanmN In-Ground ❑ Pn'asnrsd In.fmmmd ❑ Al-code ❑ Mouml124 in.of sit abl,loll ❑ Mcn 1124 inoI ant,hl,soil
<br /> Elolding"Yank ❑Omer Dispersal Con,ponnt 6'.pinla) ❑Premnunent Dev11e(111paim
<br /> Y.Dis tarsal/Prean xat Are.Information:
<br /> Design Flow(,,U Iksign Soil Afghtatian Rat MIA) Ilislnrsal Area Rnp,ind fs0 Dispersal Amu PrvPasd(s0 SYswm Fle, on
<br /> ,oro . -f— 4AIT/
<br /> \'I.Tank Info ('opacity in Total aolhl...lncm,cr ?'
<br /> Gallon, Gallon linin - _ _-
<br /> ]av tanks
<br /> Floor,rank,
<br /> lapa-rit.hhn¢ rank /eSb / T F.'l y�a.Yv✓ k
<br /> t 1-11
<br /> \'I I.Responsibilit.Sn tcmenl- I,the undersigned,assume resgmdbilits for installation of the NARIS shown on the attached pans.
<br /> I'lumna3 N;mn'(r/am) 11 tamxrs Sgnnwre NIPIMPlls Number llduiness phone Numbr
<br /> RtG/G NO /c n 1 I r �.f.5-BJ l �1J'- BGG - Y/S
<br /> Plumner's Addre,t5aaal.Cd,Sime.Lip Code)
<br /> X7760 3S W-e-Ssfrr w1. SYCJ3
<br /> VIII.County/De armtenl U.a'Only
<br /> ((yy Permit Pee Data Issued Issuing Agent slgnatme
<br /> gw APpmveA ❑ Divappmvvv 5
<br /> o,0,
<br /> Given Rau+nn na Deniol 32S oz 7-,7,-,-/4, CCr�s
<br /> IS.Conditions of ApprovallReasons for Disapproval
<br /> 1 D ECIEVE
<br /> Attach andsonjActe Pan,far m. , m:,admbmalu the eon , oroy n on,.,not n„at.nx,a.D h n•JUL 162014
<br /> SBD-6399(ROAD) BURNETT COUNTY
<br /> ZONING
<br />
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