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i,:;rrr� Cnn�ny 7
<br /> Industry Services Division (J •-,. tE/'
<br /> ' 1400 E Washington Ave SanimrY Peron,Needier Oo h Bdedin by Co.)
<br /> x\S1
<br /> PS' P.O.Box 7162
<br /> Madison,\� . . Madison,WI 53707-7162 C
<br /> Sanitary Permit Application Sene Inemia`mm" m'
<br /> :n In amordance with SPS 393.21(21.N'is.Adm.Code,wbmisxion or this loon to the aPPropriam govetmnental unit
<br /> gomd prior to obtaining a sanitary Permit Note:Application forms for stateowned PONTS are submined m P,ccc,\ddm,,lif,iRemot Ranneidnig address)
<br /> the Duportmcnr at Salety and Pmlc+sional Service. Personal infunwtion yaw Dn'vide may be u�ud forscconMry
<br /> mrNnmwitM1 the - 'ler
<br /> Alllgrientats.
<br /> lu,\se linuinn Information-I'Irase Print.\II Infmma[inn
<br /> Property Owner's Name P noel d
<br /> aa�// e7-.u-o-vo-rs-.fs-.f- or- �•/
<br /> 619010
<br /> Property Owner s Maling Achim, Property Location
<br /> i/090 Ui/aJ Rot. Govt.Lot_)_�
<br /> C'.Stamzip cede Phone)crooner R. v.. Section ,lE
<br /> S36d7 fcimleeme)
<br /> T ye N: R fr I.art
<br /> 11.'rvpe of BuRdin¢(check a8 that apply) Lot a
<br /> ® l or z family Doe ifing-Number ofDerr corns '3 d Stitel,sion Nan.
<br /> Block a
<br /> D Public C'nren al-D.xedn.Use
<br /> ❑Cover
<br /> ❑State Owned—Dc,ribe,Jo,, CSblNumhcr ❑ vilmgeef
<br /> d.zl pZl ®Town of J- J.�
<br /> III.1)'pe of Permit (Check only one box on line A. Contplen•line B if applicable)
<br /> \- NewSYstem D Rc1doemcnt5YsIron fireatifirenulhhtfirg rank Replacement Only DOher Mod0ir.non to Existing System(ex(explain)
<br /> If. ❑ Permit Renewal ❑ Vennit Revmea ❑Ctrngcof Plunk, ❑i'enrtit Transfer o New list l'revinus Permit Mother and Date lsmcd
<br /> Before F.apimtion Owner
<br /> cI Vf.'fy [
<br /> yin, POW[ Sxstem/Com onenNDevice: Check all thatIv)
<br /> p Non-Pressudaed m.Gmund ❑ Presseriaed In-Ground D At unit, D Mound>24 ii ef,uhable sod D mound 1 24mofnrimo,mit
<br /> D Holding Tank D Other Dixpetal Compunem(eaplain) Cl Preueannmt Lk'icc m,leinl
<br /> V.Dix ersal/freatmen(Area Information:
<br /> Design llow(ggl) Design Soil,\PPb RoirRmel6Pdso Dispersal Arca Re4uiredlst) Diepeaal Arra
<br /> r0 %opnaed pq SYztem[Icvation
<br /> 41 1.—7 L'+3 6v8
<br /> NT Iank Info Capacity in T." pef hlantifacrimr
<br /> Gallon, Galloas Unit- B Z _
<br /> wfanka luurinR fanW - n $ 3
<br /> Sap:a or IlMto,rank /poo (s<o
<br /> pewir,t hamar
<br /> VII. Responsibility Statement- L the undersigned,arsume rerpmndlolne fee insrallminn of the PLANTS shown on the attached plans.
<br /> Pmmb,",Name
<br /> (Me,) Piumbc"e Signaure MPIMPRS Numhr Ihtsmess Phone Nmnber
<br /> 91411 �/. /G,.0 f2..,,G-..Q f/ dd-fPSI 7iS-8GG — e-//s7
<br /> Plumber's Address ISaeen City,Su¢,Zip Cede)
<br /> 77&0 11 3S w.-bs f<., w= �rF89 3
<br /> VIII.Conottv/Deffirmunerit Use Only
<br /> Appeased DDimppeaved Penni'Fea Dam Issued Iszuing Agcm Signmure
<br /> ❑ owner Grocer aea,wm to,venial
<br /> 3ZSoo
<br /> IS.Conditionsof.\pprnvov
<br /> al/Reasons for Disappral
<br /> _/,V51,kp� &VU14&'Vg; � sf$ 3'87.30!/1) p EC�Od[�
<br /> _1z Pe SDI Afuw
<br /> Cnano,onmptere pion fir I,onm..d suenh, he , on1Y^rep+P=e on ten man a ce U I hr. vole
<br /> BURNER'COUNTY
<br /> SBD-6395(RB313) ZONING
<br />
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