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a•x..a,,sr County <br /> Industry Services Division Buren <br /> '+p0 y 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary permit Numbs the filled in by Co.) <br /> rS Madison,Wit 53707-7162 5"&(x9717/ <br /> "'i, N-/ <br /> Sanitary Permit Application SState rmnxxlon Number <br /> In accordmmce with SPS 383.21(2),Wis.Adm.QWe,submission of this form in the ii mi r u,mocramentul unit <br /> is r mood,nor ur obtaining a ssnimity permit. None:Applicmion forms for stmsowrwd p3W'I'S art submitted m <br /> the Ucpanment of Safely arM Rvf iond Smias. p,,w b,,ww myw pmvidmaybe rued foecdy N1at Address(ifdRerenthan mailing nddmss <br /> ) <br /> Purposes in accordance wiN the Prww,law,s.IS w(I Xnay Swxu 278621.ecf Rd. <br /> I. Application Information—Please Print All Information <br /> Property(Inmcr's Nmre Para)a <br /> Carl Dumb 07412-240-15-26-5 05-002-015000 <br /> Porpeny Owna's Mailing Address Property Location <br /> I Snowy(hal Lane <br /> Goh.lot 2 <br /> City,State, Zip Code Phone Number L, 'A, Scction 26 <br /> Nonb(mrs,MN 55127 651483-2833 (6hloorrc) <br /> 1'40N R15 Eo(5, <br /> 11.Type of Building(check all that apply) ac lot a <br /> ® 1or2Vamilynoodling—Nm <br /> uberofBedmomOs q.J 2 Subdivision Now <br /> ❑fnblic wva oasd—IMcnbe 1). I �e�soe/ Block <br /> El City <br /> El Same Se Own —Describe Use <br /> CSM Number [I village of <br /> V. 14 Pg.59 ® Town of Jackson <br /> III.Type of Permit: Check only one box on line A. Complete line B ifs liable <br /> A. El New System ❑ R,boxnem System ❑Iremment/llolding Tmdc Replacement Only ® Othm Modification to Existing System(explain) <br /> Addi,-zee d4 Q &i f'ra.Tlne f4ry <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑permit Twister to New List Previau Permit Number and Done Issued <br /> Beton E."imion Plumber Owwr <br /> IV.Type of POWIFS S stem/Com nent/Device: Check all that alily) <br /> ❑ Non-Pressurized lr-fo umd ❑ Pressurized InG and ❑ AUGmde ❑Mound>24 in.ormitable wit ❑ Mound<24 inofsuimble wit <br /> Dolding Tank ❑Other Dispersal Compnent(explain) ®Prowswuntf iec(cxplotoBiu-Micmhies Micrefast 075w/o Infiltrator IM.1060 T ank <br /> V.Dis naVr,amen,nt Area Information: <br /> Design Flow(gad) Design Soil Application Dispersal Area R,.imd(st) Dispersal Arca Proposed(sH System Elevation <br /> 675 Rmggpdsl) 450 450 92.50 <br /> IS <br /> V1.Tank Info Capacitym <br /> Gallons Y <br /> New TnYs Teas GaRom Units Mmmfeetur ++ V <br /> �°a nU xC a <br /> Septic u Holding Tank 750 750 I Wieser Concretecl <br /> Dosing C'hunbcr 1250 1250 1 Norwemo Bruiser ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assumr ttyr i .tall.hon of the W'IS shown on the attached phis. <br /> Plumber's Nowfifim) PI a nn MP/MPRS Nmunbu Business there Number <br /> Keith Knufixon 84O 6514704737 <br /> Plumber's Address(SuccL City,Stow,Zip Code) <br /> 927 1SOP Street Roberts WI 54023 <br /> VIAL Coon t,/Department Use Onl <br /> �Appmved ❑ Disapproved 14 irFtt Uam Issued laming Agent Signature <br /> ❑ Camaro Giern Reason for Dcmial I S37s.ucz <br /> IX.Conditions of ApprovaDReasons for Disapproval D EJ <br /> re f�j rh�tr fqa <br /> I�JS}Ull'NN 111 2001141i�} <br /> wmcb m<enpleu phm mnbe snam,ed meun to tae C...rr o.b..P.,r.^t ton sb.a m.I le roto <br /> BURNM COUNIy <br /> ZONING <br />