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Courcy <br /> Industry Services Division <br /> ?f0 1400 IF Washington Ave Sanitary,permit Number(to be billed in by Co.) <br /> )nk5F P.O. Box 7162 c_-'-7/ <br /> 3�LI <br /> Madison,WI 53707-7162 <br /> / I <br /> Sanitary Permit Application on,Tra^,action N^ether <br /> In ular duce wdh SPS 383.21(2).Wis.Adm.Code.submission of dila form In the appropriate governmental..it <br /> 's required prior to obtaining a sanitary permit. Note:Application foam for state owned FONTS are submitted to Project Ad ress(if it if IN linP�ddresz) <br /> the Department of Safety and professional Scrota, Personal information you provide,may be used for secondary ^W. IS'l Vk� "U <br /> the y �fl%Pe <br /> ramance with the privacy 1nw.,c IS.040)ml,Stull Ivry WT SHB30 <br /> 1. Application Information-Ple:ue Print All Information <br /> pro,sty Owner s Name Parol✓ <br /> -cNE:7-tG-/Y-07-S/S 7/S-a/b <br /> Property Own/!er's Flailing Address Progeny Wcation <br /> 7 0e rive <br /> Gas, ett_ _ <br /> ziip�Code/ 1'M1one Number y, 'pSectiony� <br /> SSOA/ TN: R <br /> it.l\ye,of Roilding(check all that apply) 1.ota <br /> �br2 Family Dwellin6-Number of p adors- 3 9 Subdivision Name r11 OO I <br /> Bleck k S,451l & Cs"f Ow ge-A / <br /> Dblie/Commereial-Describe Use City of <br /> SciaOwned-Uezcribe Use CSMNumber village of <br /> dial u.�a o3q ,nwacf S' "I-k <br /> 111.Type rf Permit (Check oNy one box on line A. Complete line B if applicable) <br /> 'f' New System Replacement Synem Treatmen✓Holding Tank Replacement Only Other Mod.Demon m Fixln.mg Sy stem(explain) <br /> 11. permit Renewed Ycrmit Revision Change of plumber fermi,Transfer m New List l4evious lkrmit Number and Dale Issued <br /> Barre Rxpiradon ":lm <br /> I V.Iy a of POWTS Sv9eMCom onentNcaice: (Check all that a ,Iv) <br /> NoroP,o,rumaed N-0mcnd Resinitial 1.GroundA✓Grade Monmh 24 is m,mod--mil Mound Qa in.of suitable soil <br /> Holding Tarda China Dispersal Compomcm(cxplain) Pi,tinnmeal Device lexpla.n) <br /> V.Uis ersaMern met Arco Winterization: <br /> Uesgn flow(gpd) Design So.l 1,Nci ion Ram(gpd,O Dispersal Arca Requhed(z0 Disposal Nen Deposed(so Sysmm trainman <br /> So �vs G51 lvg2,6 rola=ins <br /> VI.Think lnfu Capac.ty in Total xof Manufanurer, <br /> Calms Gallon Units c r U S <br /> \erTWa LauungTWs N <br /> U5 ea s '- U L <br /> .S yuc oc Holding TaN d <br /> hosing Chartber <br /> \TI.Responsibiht)'Statement- I,the undersigned,assume responsibility for installation of the l'i I S sham on the attached plans. <br /> Plumbu's Nam<(Pnm 5igwlure MMIPRS Number Ballor"Phone Number <br /> mid, Sy 2309y/ f7/ Po3S8/sS <br /> Plumbu's Ad'd/ress(Sae/u,City,Siam,Lip Code) <br /> �7o�Y J� CA, e <br /> VIII.Coon 'Ne vttment Ise Only <br /> plans Disapprosnd I`tnitur pee Data Ino I"meg Agent S.gna n, <br /> Oxner Given Reason for Doom <br /> 3z�oo fid- -/y <br /> 13.Conditions of Approval/Itcttsoas forUisvpprov°I tt \ <br /> H?As ALun fE� .rti� sf 3E P/ZRo/r 47- r .Ts [) r� f `/ n <br /> aF <br /> OCT - 6 2014 <br /> U <br /> ' f, A mach cp1-1111,p6m roe the:.nem and mbnuume Carol W,oPr'aper not les tbansmali ebea io slit <br /> CST- (R� m1-1111,398(R0313) BURNETT COUNTY <br /> ZONING <br />