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Industry Services Division Rumen <br /> 1 1400 E Washington Ave <br /> � <br /> I .��0. S P.0 Box 716Stantar,Pernl Number0ota filled inhy Co.)i` � �SMadison,WI 53707-7162 <br /> Srl ryl <br /> Sanitary Permit Application State Tmnxa,innNumber <br /> In aceordms o rIE SPS 383 21(2),W is.Adm Cade_xuhmn,mur or this foram m the P rPropuate gmemmenml unit <br /> ➢rc9uir d <br /> Trua to bF' a l P,,,air Note Applierrion forms ft t d POW'IS _ hnrim,d In <br /> Pm s Addren(if d'tY rnuhm mu l nt addrusl <br /> ,heDcpal Persmml- tnmlon)nt pemude Fn,is he used forsecondar, 1° <br /> lias¢- d tsithth P c'Wv. 1504(Dmy Stats. 6202SCULL'fRL DANIBURY54830 <br /> Application lnformntiun-Please Print All lnfarmalion <br /> Proper,Oxner's Name Poael W <br /> LEILA A KI ASSE, 07-020-2-40-16-02-516-790-015000 <br /> Proper,Oaner's Mailing Addrss Pmpen,Location <br /> 6202 S GULL IRI. <br /> Govt Lot <br /> Ciq,Stub, Zip Code Phone Number SE A,NE A, Section 2 <br /> DAN6URY.P'I 14830 218-340-1314 (Jeleone) <br /> TUN, Pines ' <br /> IL'fype of Building(check all that apply) 3 lSE1rLs^�'� <br /> ® 1 ort Family Dsrelling-Number of Bedroom, a Subdivision Name <br /> ❑ Pubhaconaercial-Deo,rihe Usc Block GfP '(NE L2 E'SK LoNpO <br /> [-] (:it,of <br /> ❑State Dome-Describe Use <br /> CSM Number ❑ village of <br /> ED To,.of OAKLAND <br /> Ill."f a of Permit: (Check oil one hos an line A. Complete line R if applicable) <br /> A. ❑ New S)stem ® Replacement S)smm ❑ Toolmeoul holding'I'ark Replacement Only ❑ Other Modifimsion ro I!xissiag S)ncnm(e,rumn) <br /> Ii <br /> R, ❑ Perrin Renewal ❑ Pettit Revision ❑Choogc of ❑Permit Trans@r to Nen List Previous Permit Number and Date Issued <br /> Refine Expiration Plumher Eerier <br /> /fw /l -Ll-f44S <br /> IV.'L e of POWTS S stem/Com onent/Device: (Check all Thal a 1 •) <br /> ® Nun-Pmssuriid hrGronnd ❑ Fir tt unred In-Crmmd ❑ As-Gnule ❑ Mmnd 124m.ofsuitahlesml ❑ Mommd 124 is nfxnimblesod <br /> ❑ Ilolding Tank ❑Other Disyersal Componem(e,imi) ❑Presentment Ne'ice(explain) <br /> V.Dis ersal(I'reatment Area Information: <br /> Design 19ow(ends Design Soil Appllcmam Disperm Arca Required(e Dispersol Arca Pmpoxed is System Elevation <br /> 450 Ralc(gpdst) 64286 64186 93.5' <br /> VI.Teak Dnfo C'spaciry in <br /> Collins 'total q of - <br /> Eatons Units MooufaGurtt - - <br /> Newl'vmke Fxiuing Tanks J d <br /> scpde or l bluing Took 1000 1000 1 SCO ❑ ❑ ❑ ❑ <br /> Dosing Chamber /e El Ll Ll L-10 <br /> VII.Responsibility Statement- I,the undersigned,assume resp4slbilipfar innallation of the PON"IS xhmmn on the attached plans. <br /> Plumber s N...(?,in[) Ylun sslg NLP RS Norther Rosiness Phone Number <br /> CORYJACKSON 824339 ]I5-866'8944 <br /> Plumber's Addres(Sncd,Cip',Slate.Zip Codc) <br /> 9306D1ACKDROOKRD. WF'DS'I'f R,WI 54893 <br /> VIII.CounIV/De arlmeut U cOnl <br /> Approved ❑ Disapproved Proton Fee DareIssuedIssuing Agent Signature <br /> ElOnner Given Reason for Denial <br /> IX.Conditions of Apprmal/R o sans for Disapproval <br /> SEP 3 2014 <br /> CSj �y.-/�/n nnnrn to eom,dren—mr meaneo„nd.immtna m.enan1> "g—pmermanes9rn.a a 11,.u;ndur,itURNE1T COUNTY <br /> SBD-6398(2 / <br /> 03 !4') ZONING <br />