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<br /> Industry Services Division County
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<br /> \1;\ 1400 E Washington Ave B tuzAtTr
<br /> i t\$102 . P.O.Box 7162
<br /> bladisoll,WI 53707-7162 Sanitary Permit Number(to be filled jelly Co.)
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<br /> osr-P.P-L'55' 4 734 4
<br /> Sanitary Permit Application State Transaction Number
<br /> In accordance with SPS 38121(2) Wis.Adm.Code,submission of this form to the appropriate governmental unit M
<br /> is required 044 to obtaining a sanitary permit Maur Application forms for stamowned pown are submitted to Project Address(if different than mailing address)
<br /> the Department of Safety mid Professional Services,Personal information you provide may be used for secondary
<br /> pulposes in accordance with the Privacy Law,& 15.04(1)(m),Sets.
<br /> q5 tA), M iAl Wilt. Ditm, Rtikb
<br /> L Appiteefta lorannation—Please Print All Information 3V2-
<br /> Property Omer's Name
<br /> Parcel#
<br /> .
<br /> t 7-0.3e:.-2-411-11t,,2 ,,-Z.
<br /> ROOEKT -S, 4--- i<41:ij i CEN A: it4 e C_LttrE •
<br /> -coo—
<br /> nop.ty Owner's Mailing address Property Location i 1>ir of/9%
<br /> 1-1-2_4,r - 1A)zi.-0,, viiAy
<br /> Govt.Lot -
<br /> City,State
<br /> Zip Cede Phalle Number
<br /> Na 'A, .5 i,k,1 'A, Section 24,,
<br /> 5IHO1\E VIE.V\/ , MA: 55/2..to 4,5i-z,30- /5 7g
<br /> T Hi N; R. /( E4
<br /> II.Type sof Building(check all that apply) Lot#
<br /> , — Subdivision Name
<br /> i or 2 Family Dwelling-Number of Bedrooms
<br /> BM&# iklA
<br /> 0 Public/Commercial-Desert*Use
<br /> —
<br /> 0 City of
<br /> CSM Nundoer 0 Village of
<br /> 0 State Owned-Describe Use
<br /> - Town of 'S Wt
<br /> 111.Type of Permit (Cluck only one bast on line A. Complete line B if applicable)
<br /> A. i
<br /> 7 New System 0 Replace-non System 0 Treatment/Holdin Tank Replacement Only 0 Other Modification to Existing System(explain)
<br /> List Previous Permit Number and Date Issued
<br /> 11- 0 Permit Renewal 0 Permit Revision 0 Change of Plinnber 0 Permit Trainfer to New
<br /> Befele Expiration
<br /> Owner
<br /> IV.Type a rowrs SystealiComponeatiDeyiew (Cheek all that apply)
<br /> ANtin-Pressurized In-Ground 0 Pressurised In-Ground 0 At-Grode 0 Mound>24 in.&suitable soil 0 Mound<24 in_of suitable soil
<br /> 0 Holding Tank 0 Odmr Dispersal Component(explain)
<br /> 0 Preneatmere Device(explain)
<br /> V. ' reataitt Ares isfermatiest:
<br /> Design Flow(spd) Design Soil Application Itieefspdst) Dispemal Area Required(at) Disposal Area Preposed(4) System Elevation
<br /> CO Osit 547 94 t 625, 66-
<br /> VI.Tank Info Capacity in Total #of Menteracturer ,
<br /> Gallons Gallons Units i8-,
<br /> New Tanks Existing Teaks ..e ... us .... ,... 2 g 4 2 ..V 2 -53
<br /> ....Z
<br /> ii.u 'in nm a.
<br /> ii."5
<br /> lEgilillUilill . 111111W .INMIMMEMIIMMINNerrerma 1411111111111
<br /> 11111111111111111111
<br /> va ' , . -,"', ,.' Statoisest-1,the etodenial, , ', kie installinian of the POWTS ShlOWII on the attached plans,
<br /> Phenher's Name(Print) Plumber' '' .11''''!1'41/ ItlefallPR&Number Business Phone Number
<br /> _
<br /> e0AY-I:,T,feKsDAJ
<br /> kW 6 214 334 7/5-666-'7' Y
<br /> Phanober's Address(Street,City,Slate,Zip Code)— dr
<br /> 93 O 01040( 8Rookga, was I -.7- (-La ,..51g1t3
<br /> VIII.Coda t -- donut Use S- -
<br /> At Approved 0 Disapproved Permit Fee Date Issued ming Agent Signature
<br /> --2 4--
<br /> 0 Owner Given Reason for Denial ----- ' • Pp 7/2-4//2-D Ir-). M
<br /> IX Ceadraims of App unions for Disapproval
<br /> 11.----, ECEOWE
<br /> Ansa to cometese atom ita,t*evades end evelmoit se tbeCemerey gab on paper sot les*dm A babes lathe
<br /> SEP 1 6 2020
<br /> IL
<br /> u [2)
<br /> SB13-6398 R.(R1/14)
<br /> L-
<br /> Burnett County -
<br /> Land Services Department
<br /> 1:-:i4z-it---7,-)17917.4A4 Ca -)1';414
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