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i_v\\ County' <br /> Safety and Buildings Division <br /> `p SP 201 W.Washington Ave., P.O. Box 7162 SanitanPNu- ermv Number po be filled inby CoJ <br /> III I p ,'� Madison,WI 53707-7762 <br /> ^• Sanitary permit Application state�'I'mnsaction Number <br /> In accordance xim SPS JXJ21(2LWis.Ad.,Code.,cuhm.....r oflhis umn to the appropriate go cionontal unit �-�AY IFLpV.e,.J <br /> is required prior to obtaining a sariovv penm, Note:Applicotiun forms for naternared W)U'TS ore suhmltteJ In Project Address(irdinivenl dmn moiling address) <br /> the IRpvnmcnl.1Said-,and P ofexsionul Semics, Personal information you rim,id,maybe used for secondar.' np <br /> u oxer in aaoNunce%.ith the Pndacv Lmv,s. IS 04(1)ml Slats. 3E/a$Z:N fiOAD <br /> I. Application Inform,lion-Please Print,\Il Information <br /> Pmpeny Ownds Name //'� 1 / Parcel p 0 -o " co -/ -j <br /> P.4CJ/17 � C7'7 (.'il. -31a - o -o/zono <br /> .=s Mailing Address Property'laxation PdC� <br /> S`/ / c kv G Govt tm <br /> Cit.,State / .....C. Phone Numhr Sy t y,. S4,J Y.. Section /J <br /> jj Sy�3CJ (circle one) <br /> Il.l'ype of Bu' JinIt(c Iter k a 11 that a ppWLmp <br /> ) T N: R <br /> 71Tor 21'am it, IN III l inn-\umber of Ikdroums 3 youth,won Name <br /> _ <br /> Bleck M <br /> ❑PublidCommeeial-I)e>eribe Ilse <br /> ❑Cil,or <br /> 11 State 0oned-Describe Ilse CSM Number 0vetagcol <br /> _ 4- .'nor 0AK//1Nc' <br /> ]IL type of Permit: (Check only one box online A. Complete line R ifapplicable) ir—Y-315-02-4"-) <br /> \' New Ahem C] Repaerrmm Slsmm ❑ 'I'natmenUHuldinn Tank Repluceinem Only ❑ Other hinJificainnm Pxisting Stxtem(explain) <br /> R. ❑ Nona Rene,.l ❑ Peron,R.,men ❑ Changeof Plumber ❑Penn it Transfer m New fist Precious Permit Number and Data Issued <br /> Belbrc Espiritu. Unncr <br /> IV.Tv be of POW I S System/Component/Device: Check all that a dv <br /> §i von-Po,....I,ed In-GmmJ O Pre>sua,.,d W-Ground ❑ At-Gmde 0 hmuad 124 to of,mtable soil O Mound 1 24 m .1 suitable sou <br /> ❑ Holding"Tank 0(Tlxr Dispersal Componcm(e\pkin) 0 PrcocInnetlln4cc(eaplain) <br /> V.IN, x"al/Trealmen,Area Information: <br /> iesian Flo%.input Iksi_rn Snil Application Rme(aVJsp Dispersal Area Required(s1) Dispersal Area Proposes fd) Sste a 1.11, tion <br /> 7 6Y3 6so �S 1w?-0 <br /> VI.-lmrklnfu Carve... in 'Total Muf Manufacturer <br /> Gomm Gallons Units <br /> Ne.Tnnks Fisrin6i:mks <br /> "o,or aaldiusilmk <br /> 1)m;ng Ihso., <br /> VII. Re.,ponsibilih'Statement- Lthe under nada espnmibilin frrnstallatin nflhc POWIS.ho.00m theanached plans. <br /> Pinmhur's Name(Priml / 'r Plumbefs Signawre \IPrMI'RS Number Rosiness Phone Number <br /> �m Cwt — zz7G 9/ 3Y9-7x86 <br /> Pllimbe,s Addy...Sucet.Cio-,state.zip ewe) <br /> N11,11.Couns/De artmerm Ilse Cut, <br /> Approved ❑ Disapproved 1'rrmil Fee Dam Issued Issuing Ag enanne <br /> 5 325❑(Tmcr cii.cn Ream.Ibr Ikninl 41k- &3 <br /> IX.Conditions of Approval/Rc....x for Disapproval <br /> Mull,r enm nrov Pl:m,tar me—om,nd.unma rn me mann only nn paper nnl tr o,m,n a or%D invho in s4e <br /> SBD-6398(R. H/]p <br />