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Safety and Buildings Division
<br /> ;}k; p' j7ky•,,a:`. 201 W. Washington Ave., P.O. Box 7162 SnimD ml
<br /> P,rl Number(Id d:fined'm by Co_)
<br /> "Sit, ri Madison,WI 53707-7162
<br /> `1 =; ,55895 w
<br /> Sanitary Permit Application Star, t Nalall r
<br /> cyz
<br /> Ina- d mSPS 383.2](2) W,, Ad Cd _ b 'on fth I t theappropnoie so- rd. ml unl l/wn6y It ICS
<br /> Is rryairedprior o diallimings smlar, permit Nell_Appk,rd,form,la....o„md POWYS arenbmned m P je,l Adders tldTlereol harmer(gad dress)
<br /> the Lepartmcm ot Safer. and floolessional s i rsoaal of °tion you provide map be Iced dersecondnr_v 040 6
<br /> Nuo,e, In th P ,rlm 15 D1(lym).SI I-
<br /> lurf),reation In Inrmatian-Plea se Prin I A 111 n so ren gran Grey Ro"
<br /> Prope'lrt,Owner's Name Parcelk -
<br /> /✓Oh /�4n"tfn5_0R -oJ4 oOD
<br /> Pmpoo, Ovid. 's Nlailing Addrev Pmp,n}'Lo,A
<br /> I I', M C Pt, L C C-I Lor
<br /> Ciry-Smm 7, ,d, Phan,Number y, L Section 1
<br /> Far rr i. MAI ssoati rfa asv d-7 a — (,ir,Ieone
<br /> -f ei N. u /t. 1,opt
<br /> I1. 1 pe of Bu Her,(,Leek a l l tha t n p,h) Lnld
<br /> �f l or 2 Pum,ly Dw el l[ad—Nrooms
<br /> umber oI Bad 2 Subdiruian Name
<br /> Blmek d
<br /> ❑Public/Commercial—Describe Use ❑City of
<br /> D Stale U,.ned—D,s,db,m< CSNI Nomb,, 37d47S3 D vmecenr
<br /> ✓ol. W h 32 Wdo„nni Gkki../.
<br /> HL l}peorPermit: (Check onlyomebur -Aimed. completeline Bifappli,alle)
<br /> `l ❑Kew Sg m �Replaamem Sysm DlYeaunmVHoldinalhnk Replueemem Only ❑OtherAlodificalinn IoE,11ing S11lom(ecpla,n)
<br /> B. El Plant Rcne,ml ❑ Permit Rovision D Chance of Plumber ❑Perin,lmmfer m Na, Lisl Vrevmars Pemal Number and Dae limed
<br /> Be I Own"
<br /> INra. e ofpONN IS S,.tenl/Coma emt/Derice: (Checkall thnla„Ir)
<br /> yy Nan-Portserixd ImOmund D Pessuri7ed In(arnand D AI-cord, ❑ Nlouod»J In.ofsuimbl,val ❑ Mound 124m at unuble,ml
<br /> ❑ Holdinglank D Other Dispersal Component(asllao) ❑Pmre"an't,Der,,e(explain)
<br /> \'.Dix c rsalare It cm A rea l°formation:
<br /> Dallas"I.,(gpd) Design Soil Appl,, lino Ra e,,t t) Disp"sal Areo Reyuircd In) Dispersal Areu Pmposcd('0 System Flevanne
<br /> Seo • 7 cIJ9 43J .9
<br /> C'I.TankImfo Capecily in Troll e .rinmufote"
<br /> Gamna Gnlmm Unity —
<br /> SzwTenks LxislinF Tanks _ - _ - -
<br /> 1,,an—,llddir,Tnnl:
<br /> Uasi,p Clmmber
<br /> N,IL Respmnsibdhr Statement 1,the 1 L ul P :NII fo allalian noun,ION'IS hm,man the attached pLm
<br /> Plumber s Name(Poop Plu°bet's S'gnature NIP:x11'kS M1u ober Bae ness phone 4umber
<br /> +� NiB f 7/s-8Gf-4/s'>
<br /> Plumb,s Adder(91...1,C,,.Smo zip Code)
<br /> %ill.CUnntr/D, nrtmUn Use Onle
<br /> Appm,ed ❑ Dsappm,ed P"mit I a, ��p tate Issued 1"ralAgea - aune
<br /> DO,o,r Gn—R,asonfor Demal S325ifo ��444Y 103
<br /> IS C..diItoa,ofAppno,al/Reasons rot an,a p p rural
<br /> AnoLL lo,nmPkle Plnm fur the"lora.a nd.alai110 l he(lame.0,on pope,mo,its,l'.an 3111,11 In"I'm s¢e
<br /> SBD6398(IR, 11/11)
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