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� ( Industry Services Division Can <br /> u ( N <br /> s u' 14E Washington Ave Sanitary Permit Nnmhu(to be filled in by CoJ <br /> P�" <br /> $ . 00 P.O.Be.7162 <br /> Madison,on,Wl 53707-7162 <br /> Sanitary Permit Application Sute TmnwNon Nmnber <br /> In accordance with SPS 3332](2).µ'ice.Adm.CMe,wbmimian of thi form to the appropnme govemmamnal unit <br /> iaequiled plow In nbuiuing a.ania,,wrinit. Note Apphcmino hinny lindaarnwaled PO\VTS—odonatelm ProjectAddle,,(rdnfesnrlhst mailing odd—) <br /> the Dcponmem of Safety and Pmle,,mnol Service Per mal infarmenion you provide may be used for cemndary <br /> onlmme woo the Privncv Inw,a. Is 040)(m).Smu. 541PI� <br /> lu A,elocation lnBlrunsI -Please Print All Information <br /> Praar -Owner,Name Parcel# <br /> Pn,eny ow,lo,Marne Add,,,, #trent l.wannn � ,f <br /> R rlxc Wl <br /> ear,sum "Gp Cedr Phone Number �f,it, -A section yz_ <br /> (cachedJ� <br /> 11.Type of Building(cheek all that apply) I.m# u�yu <br /> I or 3 Family Dwelling-Number of Bedroom, Subdiainlon Name <br /> Block. <br /> WbIiclCommcsial-1hmnRUxe D Oak /y�e fan <br /> Cityol <br /> Smm Ownul-Dvwnbc)Lac (11/u�-� <br /> CSM bander Village of <br /> Town of 1 <br /> IICTypeaf Permit: (Check only one box on line A. Complete line B ifapplieable) <br /> A, New S"wnl Replxanom Syaenl Treancra Bolding Tank Replazemcnt Only (other Modllilarom In Fainting Syaem dc,,Idun) <br /> X 111<1 <br /> It Permit Renewal Permit Revieion Chanycof Plumber Pennill'ranslmaNew Lut Vlermm Pennh Numhrand Das Lased <br /> Bdmc F.npimr- net <br /> 1\'.T' cof POWTS S'.etem/Com mtenWncice: (Check all[but a ly <br /> Non-Preswn'md In Ground 14eaudmd In-Gmvnd AI-Grade Mound 2=4m.afwaablewil Mound<24in.d waitabdevoil <br /> )6bing Tank Omer Oiapetcal ComPonent(explvl0 Prnrtano,o Ocviee(exploin) <br /> V.Dis ersuVlFeammnt Arca horns alio.: <br /> 1Jc.ign Flow tgWl j Deign S,nI Apphcmion Rats,nd•D Oi.penal Area Neyuind hb Di+perwl Area Pm µx1 fa0 Sye Beeman <br /> z _ <br /> \'1.1'ank❑d'o Capacity in <br /> i Mau( <br /> fa <br /> mrer <br /> Gullan Galtle Uutt <br /> 9eµ'2'µ4# poi g1vnk, <br /> saxeIll snk <br /> @nne(In.# <br /> _ <br /> CII.H6punsibilid Statement- 1,the aohnistned,a.amereryomlbilily for ilnullmial of the l'OMTSxhaw .the attached plan., <br /> PI nbNmne(Poop P m 's Sl re >II'01PN5Ivlmbcr Bn4ne�a lfione Number <br /> Ratak,,Addre-(Succll./Ciry.sun.9lp Cone) <br /> / <br /> /-'0 3 XfiYW c«? Ae - A`r/Ofa.( L✓L ��/ <br /> VIII.Comat,A) artntent]lee Only <br /> Approved I Disapproved Pennon Fee Oas jawed Hing Agent Signature <br /> Owner Given R<mon far Rniul <br /> IS.Conditions of,% cocvl/Reasons for Ills appror.I d <br /> {Perm rr 4ed'od-- Dti�12 Iss��� <br /> Perms For-Ledt,:� <br /> AnaeM1 lo„-11"o, lam rut one stn o and same In the c-ot)nal)nn P+Wx nnl len man gl -x IIrcM1es infra <br /> SND-6399(80313) <br /> BURNED COUNTY <br /> ZONING <br />