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Count. 7
<br /> / i r•� Safety and Buildings Division /J Ce r 11<7V
<br /> 201 W.Washington Ave., P.O. Box 7162 S,mmr)Pmmil Nomber(m be lined in by Co.)
<br /> Madison,W153707-7162
<br /> 5588/5
<br /> Jj
<br /> eT cion w bet
<br /> Sanitary PermSetN
<br /> Perini AppIication vlc J
<br /> In accordance with SPS 3331-lot N'is.Adm.CWe,zubmissian oflhis form m Int appropriam.....mr,nml unit
<br /> is, ,mmdprior mo blaming asanimry p„nit. Note:Applicmion Forms for stme-mmcd POWlS are submlacd to Prnjea Address(ifdlRennl than mailing address)
<br /> ,he Dspanmem of Sarr, and R,m s{oml scmie,. Personal mfam rmn.nes pm id,may be rrsd rot,eeondmy a 9903
<br /> lux,ramoomance as ch the Norm, law., 15 WI I M.).Sets
<br /> A I Iiantion Information-Plesse Print All Information (,a/c e.5 I�n v P
<br /> Poseen,Owner i Name .h Pa,celk 070>3sl Y//3 d ”-
<br /> are al" .l/• OXY 0,5- 0/1010
<br /> Properly O.mcr's%lathier Address Pa.,,mLomn,
<br /> 3 3E r?.,-/< e:.f,- leek !fir Goa.Lot ,5
<br /> Ca"Smile rip Cale Phan'Number
<br /> 51" ,,u r+'to, /g,/V SS/J'6 6'hcle one)
<br /> 11.T3 pe of Ruildi.,(check ad that apph) l Lotal T y7 N', R /,�EtygrJ
<br /> I or?Family Dwelling-.umber of Badanno C &w/ l Srol..isina Name
<br /> Block9 1
<br /> C PtmI,,'Commercial-Daxribe Use
<br /> ❑ Cirt of
<br /> ❑Stare Owned-Dc,chbe Use CSA(Numhr 62L ❑ vilme,nr
<br /> lbl. 3 Pa5c 57 CSrollage Se ,ss
<br /> I I L Type o l'Per m it ((:heck nn ly o no boa nn l in a A. C an,p lent lin e B i f app l i,a big)
<br /> A' g6ew stem CRaglmememswam ❑ FinaermdIllddine Tank Repmeamem Onl) ❑Oita plemile.sionw Eimine System(explain)
<br /> x. C"laaran Reae..m ❑ PemJt Rnisiun ❑Change or Plumber ❑P,rmh Transfer aa Feat Lis Previous Perms mamba,arta Date luted
<br /> Before Eapl,.tion Owner
<br /> IV. k eofrONN-rs S.suol/Corn onmo/Dec ice: Check all that a I.
<br /> 12KNmoiacssmoed IrrGrnund C Pressurize!In-Ground ❑AI-Grede C hlowd>_1 in.of 1mable soil ❑ %found s 21 in.of—eible soil
<br /> C Holding 1'ank C Other Difpertal Com,sncm(caplain) C Prruea ri Dr,,,c(,.plain)
<br /> C.DI. ersal(I'reatment Ar ea l n formation:
<br /> Deep Flmy(Ird) Design Soil AppIi Lma Rra
<br /> e(gad,l) Dusal Arco Required(at) DoPro,
<br /> ,,d Area Prosed(sl) S.smm Er,rcar
<br /> 30o v,19 e/3,4
<br /> CI.Tank Into Crarroiy in Total uof Slammne,r
<br /> Ganem Ganong wits
<br /> Nc.Tani, Eune Trail,
<br /> C
<br /> "a—,lloldm,Tan, 7S0 J,TO I -
<br /> Dosm,C7hzmMr See .tea !-f/—
<br /> \'ILuespon.ibilit,Statement- I. he uadeni•ned,.—notr ,mubint,fori-olUrronofthe PO,CRshown an the reached Plan_
<br /> Plumber's Name(Print) Plumber's siooawre bIV/SIPRS Number Business Phone Number
<br /> Narrator Address(street,Cirv.Sum.lip code)
<br /> 77G0 � .�.5 /if!eSSf'rr ay.t S'YSi3
<br /> CII I.County/De armmnt Gse Only
<br /> rlf�ApplmiJ ❑ Divpproc<J Permit Fee Date lseuoi Issuing Aeen all
<br /> 5
<br /> ❑O.,rrr Gi.en Reason for Dental
<br /> I.\.Condition,of Approval/Reasm,s far Disappfo,tl
<br /> Vurn n.comrleo Plan•rm me,..nm ane:umm�io me rot art,onpuar tan Int(nun a v:a m Immt,m9.e
<br /> SBD-639N(k. I I/I I)
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