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Conn;7
<br /> Safety and Buildings Division C3 f.�Y/1 t>�
<br /> 31
<br /> ;b)/
<br /> �p S"' , rl 201 W.Washington Ave., P.O. Box 7162 Sanilar.Permit p'umhrpo belilleJ inb.Co)
<br /> 1 tP - Madison,WI 53707-7162
<br /> `�a:;�==�• 558 9G 7
<br /> Sanitary permit Application State rrrma ca/nt Number
<br /> In accordance"th SPS 383 21(2),tris.Adln.Code,submission oflnis form tube upprnp ui a gn,ernmcnml unit �C4 L,,,
<br /> requi red prior to ublami ug a ernlmrp from it Nam.Appimaun firms lbr smwrowned POt\-15 are rubmiaW ro Ihoject Address(if ditTerenl than trailing addrexs)
<br /> ,he Determiner,of sant,and Pnof comul Srrrics. Peummal inmrmalion coo provide may be used for xcoi:uv 6038 a
<br /> imawses in accurdatuc xlm the Privacv Lm,,s. l ifld(INm)_Stals
<br /> 1. Appli,miu.information-Plcs,e Man %It lnrnrrnarnn
<br /> Puri Oe, N,mc
<br /> 6rPmccl p
<br /> rmp7 oa Sor Ooso A/aao
<br /> ar /-au. 4a t oaa AJAyah opo-x1302-03-qaU
<br /> er
<br /> P......O'n ',alailivg Ad roa Pm,m) Location
<br /> 6435 Grre(r Rd GoetLot 5 O
<br /> Cin',Sum Zip Code Marc Number V, A Sretiun
<br /> Oaf, 6- wt- S +y3o (enle aa,)
<br /> 11.'1.pv ofituilding(check all that apple) Lot T qe N'; R_A_L oip
<br /> [gIor2Family D„elnng-Numhrtdlledrooms 3 SuWidsum Name
<br /> Block>
<br /> ❑PubrctCommertam-Inscribe use ❑Chs of
<br /> ❑scale o„bed-Desadhe u.c CSNI Number,33772.5 ❑ vdlaeeuf
<br /> vol. IS Pa>r 19 Gera„nnf_Qp/cin„d
<br /> HL 1,Im of Ferri (Check oak one hoc un lin,A. Cmlplete time B if applicable)
<br /> A' Ne'Ssnm ❑ Rel IS t
<br /> [� ) paremen ys em ❑TrtamrnVHoldine'fnnk Rcpluccmam Oak El Other Nlodilicmion to li.aistin¢sysem(e,pl'uin)
<br /> It. ❑ Permit Ree,; ❑ Permit Revision ❑Chm,of Number ❑Permit'rrunsfer m Ne„ Lm Prc,'iaus Pcrmu Nnmhr and Dau IssuW
<br /> Hefom[,,ra ftal Umer
<br /> �1\'.T', eof PO%%I.SS„mm/Com o en Illi c (Cheri ill lhmu kl
<br /> •ISI NomPeesmdzm In-Ground ❑ Pre,ssadxm In-Ground ❑ At-(11;ule ❑Mould 124 in.of suitable mu ❑ Hound<]a inof suitable at
<br /> ❑ HOldure Tank ❑Other Dispersal Com,)-re(esplainl ❑Pmlremmenl tk,le,("Plam
<br /> C.Dis anal/1'rcall entArea Information:
<br /> Decub rim,(cd) Design Sub A"Imx oa Rate(g ddh Di,mrsal Arca Required(sl) Do,r,ai Are.Proposed(sl) S)xtam Ek,ation
<br /> yro Gv� c9 - 90 r
<br /> \'I.Tank Iota Capocipi„ 'fowl dot Nmnumammr
<br /> Gallons Gallons Unit _
<br /> Xx Tams C,isung Tams - - - -
<br /> Sepre or Holding TanF
<br /> Ikoo'chamM
<br /> 911. Re,on,ihilitr statement- Lbe under bed.+ oplmihilir,fo,i mujminn north,1.01"IS,hm nth,auneM1ed plum.
<br /> ,I, n a
<br /> ['lumber's Nomc(Prinq Pleuber's'Signmunn // NIP,\IPHS Number Rusinl�s Phone h'umlrer
<br /> 12/c/c /% /t t� S Z� /T oId SBS/ 7if 8LG-N/S7
<br /> Plumber s Address(S Incl,City.Stala.'Zip Gn4)
<br /> ) 7760 // Y3SN/e63 r. W- 5984?
<br /> %IIi.CmunWUcpartnicat fl,c Onh
<br /> Appnoccl ❑ Oisappm,ed Per— Fre Date timed lvuum,Zra,,
<br /> L1Ooncr Giem R,ason lin Dental 325 X 30�p 1ijt
<br /> LC.Cmlfilion.of Apprncal/Rcnams for Nkapprncal
<br /> \I l volt to mmPblc air,our to,o olm and m loom,to the Coca 1,_ only onVuper bol leas llmnalr.,11 incM1va In art
<br /> SBD-63,9R(R. 11/11)
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