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Counq <br /> Vex Safety and Buildings Division V(MA <br /> ;,;?j p' k• `': 201 W.Washington Ave., P.O. Box 7162 sanimry Permit Numbcr(wbe nlledinbv Cn.) <br /> ,_ ``}psi .-• Madison,WI 53707-7162 <br /> `. 665X25 <br /> Sanitary Permit Application sine /p°Number <br /> Q <br /> In accoNarce oto SI'S 383 21(2),W is.Adm.Code,submission of this(rain w the oppw shoe govcrrmmnml unit 't` 1'C1JIecsJ <br /> is wquira)prior to obtainings samorry permit. Nish:Appiemion(frc smle-ourW POW'ISeesubminul ret Projen AJdresslifdiRercmiban mailirq{room,., <br /> abe <br /> rores ma cof Safety ad liafessgi 1,Servies.s <br /> . RrsnrW information)wu wmide may be used fw secodary Q 1 <br /> to azcw <br /> orJae with Ne Priva Izw . IS OsO m smn. Q f'" <br /> 1. A2 lintionInformation-Please Prim All Information (/ Wer <br /> vmpe , Pmwlb 07-012. 'r1oYS-1 I-S I$-7/F � <br /> a, o Amo Co#3 o/Z- P�So-6 -moo , <br /> property none,s Mailing Address � prettiest,Locmion 60 <br /> ilr.N (kra Lot _ N <br /> Gn Smh Zip Code Phone Nitrate, '/., Y. Semian <br /> L.NCD N t��S� w <br /> 11.Trpe of Build ing(Check a11 that appl)) lata 3�6- <br /> T �/o <br /> 9(l or?Pumil,D ellen,-Number ofBahsoms '� SubdivismnNome <br /> �� ,rw � I <br /> Block /7 Ara/ fv/ <br /> ❑Public/Commercial-Describe Use ❑City of <br /> Q Stmc Owned-DescrieUse CSM Number ❑ Village of <br /> qTown of � <br /> 111.'1'yllkpvvve of Permit: (Check only one box online A. Complete line B ifapplieable) <br /> A' Ncw System ❑ ReTrotmamlBent olding Tank ReplacemOnly ❑Othmdl�t <br /> Mianm Listing Syum(explain) <br /> plaamem System ❑ <br /> R. ❑Ycrmit Rewnal 11 permit Revision ❑Clungeof Plumber ❑PumitlmmRrw New LiA Neviwn hsmit Number mtl OazclssueJ <br /> Bef,E,irmcr I I Owner <br /> 11'.'I' eof PO\s'IS Svstem/Com ovent/Des'Ice: Check all that. ly <br /> kYNon-Pressuntrdin-Ground ❑P,esswiaed In-Gmurd ❑Atrmde ❑ Mood>26in.ofootablemil ❑Mount<24 in.ofsuimblemil <br /> ❑11u1ding Tank ❑Other Dispersal Cmp,orpat(cvploin) ❑preuvt..pevice(explain) <br /> V. Dis mal/Preis tmeat Area Information: <br /> Desitin Him,(,,A) Design Suit A loption Ral0gpdsG Dispersal Area Rryuired(A) Dispersal Aro Proposed lsD System Elevation <br /> o q� 4a6 goo <br /> NIL I'aok Info Capacity at Twat sof Manufacturer <br /> (hallmns Ga Rom, units <br /> e4r Tanks Exinirg im4a - u - j( m _ <br /> Uu, V o, tZ U <br /> Se,sicurW Borg Tnk <br /> IkninB(hon'be, Ge/V <br /> VII.Respm,ibility Statemen i- Lthe nndersigned,assum rrspseAlogity for hoot oftbrP %NTSshmwr radar attached phors. <br /> Plu rSName(Print) Plum igm� MP/MPRS NYmM Business Phmre Number <br /> o l er 5/951 7/5 7a <br /> Plumber's Addrns(Soec4 Cin,Store,Zip C ) <br /> Z1lZo �ptf* o ✓ INeLSfelLAI <br /> ' I.Count)'/De artment Use Onh <br /> APProvad ❑DuapprovM PermitFtt Uate laved Issm or Sigmt <br /> C1 D.,ne,G'we-Reawn mr Ilene) Me2/n rl3 <br /> IS.Condi)tion,of Apprm.VW.,mns far Disapproval EVE Uofa: tP'JT3 rs on lef 3S, fjtwe ,KSo dkz�NK+ /�*36. D V D <br /> MAR 11 2013 <br /> Anarh to complete main former sahm+M auMntt m tae Csmry my x ppr aw W than 8 m ain <br /> BURNM COUNTY <br /> ZONING <br /> SBD-6398(R. 11/1 p <br />