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i Gharr Coann
<br /> X: Safety and Buildings Division L3urne7f
<br /> 201 W. Washington Ave_, P.O. Box 7162 smnmry Permit Numner Dobe filed inbI
<br /> '..+�1 psf Madison,WI 53707-7162
<br /> Stme I raryeac) n Num
<br /> Sanitary Permit Application
<br /> In eaeordancc with SPS iii 2 ry2).N'is.Adm.Cod<,submission of this form m the appropnaw uuwrnmenml unit
<br /> -s rcy - d p t b a -t ,rm \ t \ppl'-( t f f t d PON 6 bm'aed to 1'm,e,t AJdress(F d'ft,,n tFnn ren tE Pi
<br /> the Etc,umnert tS' R andI fe,Pional Senics_ 1)evenal 'nt tion>ouprova mnvh<usedhn Se.nndaR / '/ a
<br /> par,i inacchrdani the Privacy laws b.IF11Nm).Sm¢ 64o� C(ec tC
<br /> 1. Application Information-Vnnae frim All lifni-I n
<br /> Pmpem Cone,',Snmc )(_ _ Par°cin O SOS-Oep
<br /> �J O-F�10A'lO-/b' A' .p/L 11110
<br /> /.�Onertann,
<br /> Yropem wppplailine.\ddn ress Progenycaina
<br /> Co
<br /> .t,Y /tine P/PGG Gose Lot S-
<br /> Ctn.Smm ZiPCoae Phone Number y, :, Sedion�
<br /> L&- --
<br /> tin /sn /YIN .S-fGJH Iclahone
<br /> 11FBuilJink(check all shut apple)
<br /> Lotti T 1(I N'. R
<br /> I or 2 Family Dwcllin_•-Numar of Bedrooms 1 SubJiHsion Kum=
<br /> Black 0
<br /> ❑P01.0Commereial-Dexri0.(ke ❑Cil,of
<br /> ❑State Owned-D,enleUse CSNINombcr ❑ Vlliegeof
<br /> ? 3d TS Tm,n of
<br /> Ill.'I, eoffermi= (Check only one boa on line A. Complete line 11 if applicable) 0 A— — ��
<br /> \- ❑ N,,v Svstent ® Replazement System ❑'r,ii1ment4loldine I onL Replm,Pa,m Only ❑Other\Imlilication to Fslain,S,'em lesplain)
<br /> 8. ❑ Permit Renanal ❑ Fear,,Revision ❑Chm,of Plambn, Per." F armlet to New List Pavinvz Per.,,Numher and Dete Bwcd
<br /> fidoa Eapimtion Amer
<br /> I\'.'1', vof 1'0\\"1'S S,xtem/(:mn o eatll)e,1c (Cheek all thatat ly)
<br /> [RNno-P,,,odadIn-Gra nd ❑ I',LuurivW ln-Grulmd ❑ AOGmde ❑ mmnud>2t in.ofstrimmc-soil ❑ M11und<24 in.of Airdble 51111
<br /> ❑ Holdine Tank ❑Other llispcml Cmi,m,m(esplam) ❑Pre...mi Device leaplain)
<br /> A. Di, ersal/I remn"ot,\rea Information:
<br /> Iksien Firm 12Pt) Dy,nm Soil ApPGcvtion Rau'(I{pdsl) Dispvonl Arca Reyuirttl(sU Dispersal Aron Yroposcd(rt) Sazmm F,lewtimn
<br /> 300 • 7 4f k
<br /> 1 aak tofu C.Pxmn In Total hof Mar-faaoner _
<br /> Gallams Gallons Uniti _
<br /> le, 'ek, F—Ion,Tan4 - - -
<br /> Septic a,Hnldag Tark /OSO /oS0 / �nh: 4.r.f01 X
<br /> Fear,CletmMr
<br /> \II. 11 pn in,ihilite S l atein en 1- 1.theniter _ned.a eapmnibilinfnrmoalla two or tM1r PO\a"I N ahnx n on the attached Pla nes.
<br /> Plumber's Nnme'(/Pnn) 51 `
<br /> I'lUmmbnfvt
<br /> �Slsvueee �%1n1MPRS Number Rusin...Phone Number
<br /> �IC/C IK-I f
<br /> Plumber's Address ISveep UP.Si.,ZIP Code)
<br /> f 77 0 // 3.i Gv e.9_JF i 6(1 S H85.�r
<br /> VT .C,nunR/Ih arm,ent Use Onix
<br /> for De
<br /> _ Appmvd ❑DiuPPoxed Par to Fac yj hen,lswed Hsuin ee Siemmrc
<br /> ❑O„tier mxar Iinial 3 25 +0 .(/ �AY2ol�
<br /> IA.Conditions nL\pprm aVRca.nm for Diapprnyal
<br /> .ama+luruinlntleplan:rnrm<f>uouunil,ueininn m,1.1 . nary r. PUPTonto-..mon nv:,a trod lnai-
<br /> SBD-6794(R. I1/11)
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