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Industry <br /> ��raany , Services Division county <br /> \ 1400 E Washh%ton Ave <br /> P.O.Box7162 <br /> Sanitary Ptxmk Number(to be filled in by Co.) <br /> Madison,WI 53707 7162 J 2 4 6//J S 44-3 <br /> Sanitary Permit Application smote T1 ne ian"'umber <br /> In aocordatree with SPS 383.21(21 Wes.Adm.Coder submissim offlm form to the appropriate svernmental ulfit AJA I L <br /> Is >md to° a Y Pit Now forms fix state ewmesd POWTS are submitted to pto' <br /> the Department of Safety and Professional Savices.Personal information you proves may be used for secondary Pro Addles(if defferead than mailing address) <br /> in accoutre with the taw t 15. l mI Stat& <br /> l Apprication lafm"ation-Pkaae print AB Inarmatiaa <br /> Property Owner's Nam # 07-020--2-#0-A0- <br /> AAe—V DSO �4 p -T /5'1051— OZ3000 <br /> Property Owner's Mailing Address I�oabian <br /> �(sz1`t <br /> city,see zip code Phone Number <br /> !ts %y Belson <br /> 0AA!5uVJ u �ls���., 7/5-421,-177.5 T �IU � R�E�w IL Type ei$ g(eitxk all Zlmt apply) Lot# <br /> ❑1 or 2 Family Dwelling-Number of Ba t cams Subdivision ZFame <br /> ❑PubiirLComatercial-Dexsc•rebe use 64-,kt A,,J) <br /> ❑city of <br /> ❑State Owned-Describe use CSM Nem►l= Q Vetlage of <br /> /.3*r#PCe.!Vx .-- j1d Town of <br /> III Type of Penwit: (Cieck only am:box an lime A. Catupktne use B if appmeaw <br /> A New Sys ❑Rat System ❑TreaftneWHolding <br /> Tw*ReplacementOnly Q Other Madificaiaon to Existing System(explain) <br /> B. Q Permit Renewal ❑Permit Revision Q Charge of Plumbs Q Ptxmit Transfer>n New Last Reviors Permit Ntmsbet and Date Issued <br /> Deface Expiration, Owner <br /> N'T of POWYS s Cieek all Bart <br /> ON.n-Pressm.,ad la Gronmd ❑Presssai ed ht1 hmad Q At-Grade ❑I•M,%md>24 m.of suift sot? ❑Mound<24 m_of suitable soil <br /> ❑Holding Tank Q Odw Dispersal Campamem(©rplam) ❑Pre.Device(explain) <br /> V. newtowat Aran Lformatka: <br /> Design Flow( ) Design sot? g Area Regtt6ed($fl ll Area Prapaeed(sf) �Elevation <br /> VI.Tank safe Capacity en Tonal #of Mrnu fchm <br /> Gallons Gallars Units e <br /> NewTadrs See Tans <br /> R <br /> _ aC� C7 a <br /> VIL "k dw andwakme4atar� for iaala "iea of tie PORri 3 atiowa de atgelei saes, <br /> Plmnbe='s Ntr�(Prim) Plutn>>er MBWPA•Number Btsin=Picot Number <br /> eopw_-T-TWKS" r� <br /> Plumtxr's Addnss(surd city,Slaty zip code) 92 11 33 <br /> 93Ob ttPeK BRcorc rma, tv u,�x Wf <br /> Val.C Ilse IV <br /> Armed ❑DWffwvad Pftmitlice nac�t�,ee > AIM <br /> �' t <br /> Q Owner Given Reason for Denial 375. <br /> IX Ceeditiem of A w2IMtmseas for Dbappmval <br /> Burnett CountynepartmeAt <br /> `1 <br /> Atets6 to eamydele plus far ace s�s/s sit sal�it to tie Cae�y oat It!1aa <br /> SBD-6348(R.08/14) <br />