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/.,- V•: Safety and Buildings Division
<br /> 201 W-Washington Ave.. P.O-Box 7182 sanlwr 9tnnrt Nnntbcr uo be 6ncJ in b Co
<br /> r�r„0 .' a• 9 > > J
<br /> Madison,WI 53707-7162 ) t \
<br /> r.T:ar.
<br /> Sanitary permit Application State,.an,acdon Nnmtwr
<br /> Xlln Codc,abrussionnrd(s into in the appropriate ovelin"n"Ido.,
<br /> uncured 1l ,, blain GRED parrot pPR
<br /> Nnre.Aotion tbmPOW
<br /> IS lm stacmed POIS ore subm P
<br /> rat roject dJdraslir dllcour rima maaddressDetermiDeterDetermined, lar,
<br /> the Deneor sale,and Poor ssmrm se"e,. Personal int(ammlon VW pin.ide me,,be.,ad for on,'ad—
<br /> mance.,im are eri.an l.n,v.s. u.am>tmosrat, Lora Lle AaP.
<br /> l�nte- enlicalion lnfnrm:eii -I'Io:1)e frim All lnrnrmaron 1 I
<br /> Pmpeny o,aner s Name VIA P,e,l a
<br /> w< !f P , 3103 eJ 4/08 C17ao
<br /> Properly Colors's%rating Address Proper,I.na-otion
<br /> 307 1-t Lor 6
<br /> Cin',Sate Zip Cao, Phone somber �q '6. Section
<br /> /Z aLl,.Jfei /yIN SS_9,e& Idrde°°`y
<br /> Iota f
<br /> 11.1,,ur ,Ituild in•_(cheoF all that appb I II
<br /> �Iorl rumily Dxelling-Number ofUedrtwms ^ / SuMtivision Name
<br /> pluck er
<br /> D Public/Commercial-Describe Use 0 Covet
<br /> 0Swte Omisd-Describe U,e CS%I Number 11N or
<br /> Vr I �—G M :i"'a on, 7Y
<br /> I ll. Ib pc of fern,i e (Ch ed:on lc nn a her nn l i no A. Complete l in Bif applicahle) - - -
<br /> \' ❑ Nes,Sysmm Ij31Lp1:dement Sust°m ❑Trea,lcm,T hold Ing Tank Replacement Only DOthur%Ialilie°tion to Exil Scsran(c,plua)
<br /> It. ❑ Pennir Runnml ❑ Pennir Revision D Change of I-lumber ❑Permit Fourche, sew Gsr Pre.l°os Panama NunlMr and Dam Issued
<br /> Raine lSspimrion Umcr
<br /> �1%.'I'e cof PO\\"IS S,lerniCunp nn an One,ire: (fheeF all thalat Ic)
<br /> 81{Non-Pro,uracd In-Ground D Preszerized In-Ground D AI Grade D Mound>24 In-of soiwble sol ❑ Mound<2-1 in.ofxduome,da
<br /> ❑Iloldina lank DOther Dispersal Component(explain) D I'rtarcarment Device(espbint
<br /> \'. Di, goal/Irratmenl,%rea Infonvtion:
<br /> Design Flo,(ppd) Design Soil NPli,w I kamlgplsD Disperxal Arca Rymred(°t) Dir,,rsal Arca YmposrJ Gt) S), an ties on
<br /> 3mo r � o0 600 53. c
<br /> \'I.'1 ane Into Capa-r,m rural dof kboaracrnrcr
<br /> Gallon, Callon, 11:It1
<br /> ve..rans, E—o",Tanl, _ _ _ _
<br /> c -
<br /> SePmmOddint'park /p S0 /oS0 / T„ Pr/,{.. it,
<br /> Doeme chamber
<br /> \'11. R<spon,i It i l iq Va le men l- Lthe underc aed.a e.po,.ihlli1,innmmllafion of the PO"Ihon,S+En on llie:nwchetl plait,.
<br /> Plumbers Name U'nnp 1'ImntxSisnatma .\IP.',\[PRS Numhr Ras ass Mme'Sumber
<br /> /7,Cle h: /e,� 1 /2� .P ofdSds/ >Gs-X66—Y/sem
<br /> Ploniber's Addr,e ISrnm,Cul,sire,7,Code)
<br /> X7760 -!r_VF9-3-
<br /> -NJ 11.Goon,,/De urtment li\c Unl,
<br /> \ J 0 Disappm,od $ermir Pee Darn Issunl Issuing vont Slpnanue
<br /> o,e O
<br /> ❑(T,nn Giron Raysnn for Denial
<br /> I].Cnrtdiron,ofappru,aUR,r,on, rot Di a,,ro,al
<br /> p Scit C�OdC�
<br /> 013
<br /> .at,rh Inc mpmle mm..,n..Die . r.n..m out ulmtile ens _ nm,ou Paper n^u..,list,xn ,e
<br /> Sim Ji395(R- 11/11) BUR ETTCOUNTY
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