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Conroy 3..�1<�/'
<br /> /-ars'. %ks Industry Services Division
<br /> 0r=r 1400 E Washington Ave carries,Proton Wrmher he be tilled in be Col
<br /> SPr is Fi P.O.Be.7162
<br /> S Madison,WI 53707-7162 J7 /3�tJ
<br /> Sanitary Permit Application So,, Ir wars..N"nber
<br /> In incontinencewith SPS 383 2 r2),Wi,.Adm.Oak,olu fission al this four to the appropriate govemmem —7111,
<br /> al unit 78/7
<br /> Is 1.1nad or to obtaining a,vmmry pmnit. Note.Applieation fomn rnr seutoowned PON'TS are ad, led to Prs,k Address(rdilI It than mailing address)
<br /> the Depanmem of Satin and Profcoontral Scrvics. Personal alley inn you pnrvlde may be road ror mconMry
<br /> purposes '1
<br /> accordance with the Procter Low,s. 15.LL50)(mL Stats. 7 GG s P"SP ee n 161.p
<br /> IApplication Information-Please Print All Information
<br /> Property Owners Nome Pnrrvl a
<br /> 0.ra Ge 1,1-'15 o}ozo-CYa-( -Zo-S/r-93/-.Ztatao
<br /> Proper,Owner's Mailing Address Propem I oration
<br /> 7GGS /�-o sP res e
<br /> G.O.fon
<br /> City.sore ziv cone Phone Numhr ,n. v., see6on
<br /> Webs/<.. GST S'v953 mircleon,)
<br /> II.T%pe of Building(check all that apply) Loa T NG At k /1" EoRol
<br /> RI I or 2 Family Dwelling-Namur of Bedrodlm 1 Sutchvision Name
<br /> Hmrl:n l�/!CAGE of ELtol./uNt6 Ab.A-a
<br /> ElPublir.Commereiul-Occults use ❑City of
<br /> ❑Bute Owned-Descrihe Use CSM Numlao ❑ Viltage of
<br /> 111.'1'vpe of Permit: (Check only one hos on line A. Complete line II if applicable)
<br /> `\' NewS t 0 Rc '
<br /> yzmn psemrntSygcm ❑'1'renunrnvllulding Took RcpinccmentOnly ❑ Other Motlilievtion to Exisimg$ystem(egdnin)
<br /> B. oPermit Rancwal O Permit Revision 0C1her,at'PlunM:r ❑Psmrin Traleferm New- Lml•m iotas Permit Number and Dare Issued
<br /> Belore F.mimtion Owner 4,' ss, 3, z s16-o6
<br /> 1\'.'Yv re of YON'1'S SvxtemlCom o cot/Derive: (Creek nll that n s eb
<br /> ❑ Ron-Prcssuriatl In-Grouad O Perwarizal).-Ground 0A,Grode ®turned o L in.ef,uiWble it ❑ Mound a 24 io.afmitable mil
<br /> L) Holding Took ❑Othor Dispersal ComprruaAaplobl) ❑Premaanem Dcvicee,lon)
<br /> V.Dix nersal/I'reatmcn[Area Information:
<br /> Ocsign Plow(gpol Design Sail Appliention Rntdgpd,O Dioycanl Arca ll,,oued et) Dispersal Are.secreted(sl) Syann Flevmion
<br /> 30o f ]>., 1 3,76 14�. .!
<br /> VI.Tink Info Capacity in Total not Mnnofourelr
<br /> Gallon Gallon (Joins - t
<br /> ..taskr
<br /> ` V YJ
<br /> Scale or holding Tank /d SO /f,50
<br /> IM,i.g CM1,mhr 7SO �0
<br /> 11.Responsibility Statement- k the undersigned,assume responsibility for installation of the PCAVI N shown on the attached plans.
<br /> Plumts,,N'mneOiron Yl�umber','S"courure, M1IP/bn'RS\umber Business Phone Number
<br /> RIc/c IV,, /c r1J 'I 1 716-86G- N Is, 7
<br /> Ylmnler-s Address(Sher,sty.Sere,Lip Code)
<br /> ,17760 f/ -3� r we G t,>',— t✓r ,S>.¢S 3
<br /> VI II.Co. t,/De :,rlment Use On b'
<br /> Algrmvtl ❑ IIimPProval Permit Pec Urelssucl kering Agent Signature
<br /> ❑(Hoer Given Reason for Dould � Jc� n
<br /> �i y�y
<br /> I.C.Conditions of Approval/Reasons for Disappoint If �c1 S V �`
<br /> OCT 2 7 2014 D
<br /> Morn momple,path for al loonaund.unmrn,mreuu . only ,pape. rnsutll��nommeN J / BURETT COUNTY
<br /> SBD-6398(80313) ZONING
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