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<br /> Safety and Buildings Division
<br /> 0 k 201 W.Washington Ave., P.O. Box 7162 tianna Permit Numhm no be,tilled in hr Co.)
<br /> \�SPsj Madison,W1 53707-7162
<br /> 'l•>µ
<br /> Sanitary Permit Application state/r�m 'rn"action Number
<br /> In accordance with SPS 383'1(2),\Vis-Adm.Code.submission ol'this for,to the Vprop^ale g.scmmmnal unit (. Y 4--vicp✓
<br /> is required prior m,obtaining a San ILan Permit. Note:Application fomes for stale-owned POW IS are submitted to Project Add ress(if different than mailing address)
<br /> the 0cpanrent o1'Saki S mW ProtessionaI Senics. Personal inlormminn.' u pnai ac be used for Seconder,
<br /> u pp
<br /> o e in accordance xilM1 the Privan'Lmsa. 1�0.1p)Im.Sai
<br /> I. Application Information-Please Print.all lnfornam an e, B.Z.ZU 6kVA)jL6OpJ /IOarb
<br /> Prop�c11ny Ovon,,,Name LL 3
<br /> Parcelp 17-030-e'2..yc 6- '
<br /> /v W P_—`-5n �..� L Oh05: , 3 - a//bcO aab-4 3 .pf
<br /> Propcny Owner's Mailing Address Propmn 1Temion
<br /> p i
<br /> g 6 / Ni ci r/ Govt.Lot 9
<br /> City,State/ Lip Gyle Phone�N./,.h/,ey,, ', Scanno�_
<br /> 4A)64/' L✓ - 5y�30 (circle one)
<br /> p
<br /> 11.1) e of Handling(check all(hat apply) Lot<
<br /> Y�1 or 2 Famih'Dnelling-Number offlydravns - 3 f SuhJivision Name
<br /> Block#
<br /> ❑Public/Commencial-Describe Use -� 11 Cit)of
<br /> 11 State Owned-Dascribe Use I CS%I Number C1 Village of
<br /> V/7 p is of p �1.k/ y./
<br /> ll1.'1'ype of Permit: (Check malt,one bac on line A. Complete line 11 if appl ira Inlet
<br /> >'
<br /> 11 N,,S)s¢m �Itepinnmem$stem ❑'I'rcmmenUllolJing Tani Replacemem(MI. ❑(#beer Modilieaion to G.ining Scsmm(ecplain)
<br /> 11. ❑ Petmil Renewal ❑ Permit Recision ❑Change of I'lumher ❑Pcrmil'l mnstcr to New Iis,Previous Permit Number and Data Issued
<br /> Bemre r:,nimti.n rn.a«
<br /> Irtrtff%Ff1 pe of PO)YrS Svstem/Component/Device: (Cheek all(hate M
<br /> ;#loon-Pro...imd In-Ground ❑ Pnssorimd In-Gromnd ❑M-Grade Cl shoed ,24 in nfs enable sot ❑ Mould 124 in.of;.;table ,,it
<br /> ❑ Iloldir, look ❑Other Dispersal Component(evNain) ❑Pmtreammnt Leviee(ry,lui,o
<br /> A'.Dis er,ti real, on[A rest I nforma(ion:
<br /> 1Rsign Flats Penn Design Soil Application Raic epdst) Do, .I Arca Reym ed Iso Dispersal Area Proposed SO Asram Idesalit on
<br /> So 7 --v3 ,/-5--0 9> 0
<br /> AT 9'ank Info C.,ren,'iit 'I'.ul pof
<br /> Manufacturer
<br /> Gallons Gallons Ilthos _ _
<br /> New Tants [aistiny'fanks — —
<br /> - J
<br /> Sephc orlmr /ooe7 — /dao 2q6 /
<br /> A.....Ch-ricr
<br /> V I f.Responsibility Statement- I,Ihr undcrsiartrd,avmnr -,xroibilin for instalhttinn of tar I'O%N' S shma a on the mpohed Plans.
<br /> Plumber's Name(Print) Plumber;Soomum \II'IAfI'Rti Number Business Phone Number
<br /> Plumber's Address Street,Ca ,St a,w Zip Code)
<br /> 6 0 X -5--/ Si/e —r /-jJ- �
<br /> V,II 11.County/De arttnent Use Only
<br /> Appm%cd ❑ DisappmreJ Yenni[I've Dam Isw.J Leming Signawn,
<br /> b
<br /> ❑<hsna ciao,,Reason for Ixniml 5�0 8 U, X13
<br /> I\.Conditions Of Apprmml/Reasons for Disapproval
<br /> Attach to complete plan,for the sfgem and mhout m the Cruets anh on paper not less than 8In..I I ruche%more
<br /> SBI)-63981R. 11/11)
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