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oornmeree.Wl.Jov Safety and Buildings Division Conn <br /> 201 W. Washington Ave., P.O. Box 7162 ?4YYle+ <br /> i SCO n S i n Madison, W1 53707-7162 Sanita Permit Number(to be filled In by Co) <br /> Department of Commerce /-�Q/ 19 <br /> Sanitary Permit Application State transaction Number <br /> In ac.ord,mce ,,Ih s L omm. KI 21121.W is. Adm.Code,submission of this form n)the appropriate governmental <br /> U1111 is required prior to obrammg it sannary permit Note. Application forms for slate-owned POWT.S are Project Addres. (ifdilTerenl than mailing address) <br /> "uhmmed m the Department of Commerce. Personal in torntalion snit pnwide may be used for secondary y <br /> u e es m accordance with the Pnvac Law,s 15.bull Xm),Stals. Op� p_ s.,,t f�d <br /> ljcarncr Information-Please Print All Information as CC �F <br /> Pronpem Uwtier's Name parcel# 07 .�/ + 7.1u"il <br /> fC_o� d f tar 0 (�-#3� �5 1Y0.3 0y-OOD a /d1.000 <br /> Propem lhtner's Mmhne Address c Property, Local moo/r03 _03-33:3'o <br /> tO/p-0 A Me• Govt. Lot <br /> i-lis tie Ztp Code Phone Number <br /> W '/. <br /> S <br /> �/ , Section <br /> telnlr d/rS • /'Vl /11 <br /> n SJ ai0 -TS /,'O SZ �Oq Q (circle onq-1 <br /> �i <br /> If Type of Building(check all that apply) � Lot a <br /> I or 2 Tamils Dwelling-Nnlrlber of Bedrooms_ Subdivision Name <br /> Block q <br /> r] Pubh.tom mcroal-Describe Use <br /> ❑ City of <br /> -J 'tate Uw tied-Uex ribe llse C'SM Number ❑ Village of <br /> Town of <br /> 1 III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 0 Ness Ssslcm ❑ Replacement System ❑ Treatment/I lolding'Iank Replacement Only ❑ Other Mudi cation to Fxtsung System(explain) <br /> B. 'F7 Pemui 12enew al ❑ Pennn Rcvulon Ll Change of Plumber ❑Permit Transfer to New <br /> List Previous P ruin Number and Date Issued <br /> Helitre P.xpiratmn Owner <br /> IN , Ts )e of POWTS System/Com )onenUDevice: (Check all that apply) <br /> Now-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade EJ Mound s 24 inof suitable soil ❑ Mound s,21 inof suitable soil <br /> _ Holding Tanis D Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> I Dispersal/Treatment Area Information: <br /> Iksten Flu" (gpd) Design Soil Application Ratggpdsl) Dispersal Area Rc aired(sl) Dispersal Area Proposed(sf) System Elevation <br /> 41SO 7 6 6 <br /> • 3. <br /> t1.Tank Info Capacity in Total N of Manufacturer <br /> C <br /> Gallons Gallons Units � � 0 <br /> Ness finks Ifxisurig ImiAs u c u u a � � a <br /> se a r1loWmpla�is 010 I wfl30X <br /> IXuna i ham tar <br /> N 11. Responsibility Statement- ],the undersigned assume responsibility for installation of the POW LS shown on the alta hed plans. <br /> Plumper : N`amt W/�inti 19ui hers Signmure MP/MPRS Number Business Phone Number <br /> it k� e 2tS2Z if 6—mar <br /> I Plumber-s Addrees l Street.City,,State,Zip Code) <br /> 77tis'_ , Rl D W 6s�►- <br /> Ill. County/De artment Use Only <br /> Permit Pee .n Dale Issued Issuing ignaturc <br /> -x PPnts ed Uuapproccd S % _ <br /> _ a O"ner Given Reason flit Denial ��� <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> \ranch ui coniplrt<Plans fur the..sant aair submit to the('aunty ,,it, un paper not less M"', <br /> a I -I lir r3 2007 <br /> BURNETT COUNTY <br /> ZONING <br />