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�yrnx V;y ln&*y Services DivisiDa t'Oafflt� <br /> 1400 E Washington A.ve <br /> lift \'T ' P.U.Box 7162 <br /> Sanitary Permit Number(to be fitted in by co.) <br /> MadisoA WI 53707--7152 c�1 J- 19-'1/C9 <br /> '7 <br /> �L <br /> Sanitary Permit Application State Trawacfion Number <br /> In wcordance with SPS 38311(2),wis.Adm Code,submission ofthis farm to theappmxime Pv unit IV <br /> � (¢1 R88 <br /> is rsquacd pnor to a sanamy Permit:Mots•::Application fimms for PCytU'1'S we Stitimitted to Proyvct.A (if rhea rtlaitlrfg ad£1teSs) <br /> the Depar buct of Sa£dty and Profewootiat Semws • You may be used for sauxubuy <br /> to with the PrivacyLaw,s 15. 1 m Stis- <br /> Property t)+vrter's tvtmte — ..� <br /> 4`t"', <br /> Prepertyouxxr'sMuthng Addr6ss <br /> Ripe"Location <br /> City stagy zip code ! Sect. 23 <br /> t - <br /> ( <br /> circk <br /> H.Type of in(chmk A&a zMAy) Lot 4 T `'� N; R 1 <br /> l or 2 Family <br /> Q eDwellin:�CRDfBedrowis <br /> Sf; r7ow <br /> PublictCoam e <br /> � Stibd'evisicm <br /> Q City of <br /> Q Sude Uwncd-Dmribe"Use CSM Number Q Viftw of <br /> ___.--- ✓..- ,Town of 7�L�-��1�7 <br /> I13 TYPe of Peamftz (Cbeck oaty ow box crux Hm A. Cempkft Kne B if ) <br /> tg. <br /> Q New System Q Replacement Systan Q T=MwMWHoWmS Tangy Reg 0Wy 01ber Modifuxtion to g Systemm(e. lain <br /> R• ®Permit Reacwal Q Permit Revision Q Cbmwapitanitxx ©Perinit?rsrsfer to New ` 2d <br /> List PYevious iteruiit idaimt ec a+ui Date <br /> Eefuae Expimdon t3wrter <br /> IV.'[' 01'P't)WirTS� ( s113�st <br /> ©Pr essuziast In ®At Grp QMound>24 ire of suitable soil Q <24 in,of suimbte soil <br /> Aif-J i)cvitx{rupiairi} <br /> 'I (.0 System Elevat. <br /> VI.Task Info C -ty intsi ToY � 8 or Mamr <br /> C+ullons Units <br /> o c, <br /> NewTaaks <br /> 50 <br /> 000 <br /> Siraie -I, understxed,Wisume responsilaility for inxtaffstlm ofthe poWS Pu�m'bC)eds Name(Print) <br /> i ttains Sigre <br /> `uEnr <br /> 3 mr 3' <br /> Plamixss Addres(StreetCSe,zip Cad) <br /> `] <br /> use <br /> 0 erg POtait Fee Date i A t.S- <br /> ©0wnes(`riven RE=_i $3, lei t <br /> UL Candhkas otAp fin Dbapprwa <br /> APPROVED <br /> At e9 ro P &�t ao @fir c *+eats— i.d. t <br /> SBD-6398(R 08f14) AUG 19 2019 <br /> Burnett County <br /> Land Services Department <br />