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Safety and Buiklings Dimion eurwkg <br /> \S P'{... ;I 201 W.Washington Ave.,P.O.Box 7162 Saliery Permit Number(w he Filed in by co.) <br /> Madison,WI 53707-7162 <br /> '. .�5594�8 <br /> Sanitary Permit Application S Tmwctm Nnmbe, <br /> Inaccurdarcewilh SP5333.21(3),Wis Adm.Code,submission ofNis tambac aPleoPrmte�rmvomtal sink v Yl2Ul 1 {1 <br /> rcaaired prior w nineping a sionmv Permit. None:Applimim!for ante-r"-1 PONfS one fabourind m Project Addres(ifdific-1 then mailing addreszl <br /> the Depm ort of Safety ad Pot ioml Scrvies. Pers 6lfurmmun you povide maybe 1 far steed <br /> c1.1ce wish i. - law,s l>Olt l m Sorts. / <br /> I w Application sc Information-Plense Print All Ipformaruo A <br /> 1 E <br /> Propcm OtmcJlriN�}� 1 Forced N - <br /> G�/kCMI O OZ-Z47 al' OZ- ollla� <br /> Proprny Owmcr's Mailing ddrcss Popero I... <br /> l 3383 ��F Dn,, Lnt — <br /> C. ,/S'ate f1,�/�� 1 r Zip/CJdOe Phan Namba ���[(/G' L'/., Semon <br /> 6ML! . ;Y w W. SIO�� T N: RE <br /> It.Tvpe of Building(check all that appl)) lAla <br /> I or 2 Fondly Ue <br /> scilit -Numms <br /> flounder of Bechoo � Subdivision Name <br /> Bork C <br /> ❑PuMie/Commereial-Desenhe Uu D City of <br /> ❑sure Owmd-Dercribe Use CSMNmnher 100130 ElVdlageor <br /> V23 P/W KTowmof wrsr//laahks�d <br /> DL Tvpe of Permit: (Chink Dory Dor box ov fine A. Complete Enc B if applicable) <br /> A_ DNew System Repkeepaau Only ❑01her Modifrolimm Exiuing SYuem(exploin) <br /> U. D Permit Repessal D Permit Revision D ehenge of Pbmtbor Opcpap'Tpapvaprlcw List Previwu Ikrmit Number ad Dac 1.ouN <br /> Befolc F Pira ion D aaa <br /> W.Tv pe of POWTS Svstem/Com onesMevlce: Cheek all thul.2plyj <br /> qNon-Pnssunadln-Gtoud DP ienil"noud 0A1-Grade OMprdaNirtofounial l DMomd<24inorsuieblesoil <br /> OFloldifg Tank ❑Oder Dispersal Campamnt(explain) ❑Pmuwmcm Devim(eeplain) <br /> V.Ois enanocatment Area li formaion: <br /> Dezign Flow lgpd) Dcsien Soil Applican.Rate(epdq Dispaanl Ana Reyuirai Disperml Arm Poposd(st) Syztan Elevation <br /> // o 1 1 GHz PMO /3 f25 <br /> \T.Tank Info Capaai in Tool aof Mamfacpncr <br /> Gallen Caguas Uniu <br /> Neo Turk, Fyalrq Tear, <br /> p.U - U <br /> Sex"orthan"Tad / /� <br /> W .'CMmW <br /> \'11. Responsibility Statement-1,the undersigned,assume minmSM1ilhy fpr instlYation of f is FONTS shown on the atuehed plana <br /> Plu is Name(Print) PI MP/MPRS NImlber Business Phsme NumMf <br /> o( 5155 7 '; 7a <br /> Plumber's Address(Scaet City,Sete,ZipC ) <br /> Z7x& �inr 3 ✓ Wc`���w:54f54 <br /> VI 11.Coup h'/De eminent Use On h' <br /> Approved D Disappovd Be.. knnif Fx Dme lined Imsing A iefmsure <br /> ❑Omer Given n for penin penins <br /> 13 Mfi113 <br /> IS.Cnndilions nL\pprnvaUReasnns for Disapproval <br /> \vra m rnmp4)e Man 6r Ne nao-m aM subeilro tae CnmhOnl)w pper^nr It01W a N_a t <br /> MAY 13 2613 <br /> SBD-6398(R. 1IM 1) <br /> BUR ETT6OUNTY <br />