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�J Yri�• Connly� 'L <br /> psi <br /> Xi", Industry Services Division c.✓✓t LiT <br /> t400EWashington Ave Sanitary PcnniW unlller puh filled in by Co.l <br /> s ( r. P0.6ox7,fi2 s66963 <br /> .x\ `p- Matlison,WI 53707-71fi2 <br /> -- SO,, Itamaalon NmnMr <br /> Sanitary Permit Application <br /> inacc d 'h SIG 3x1. 1( 1 AA -'- AI Cade, b '.' fall t th 1P p governmental mt <br /> ntlired pdor a returning tru t Nle Applicto forest for rated IPON fS' submitted to PnsectAdd (tuftsin than taring addressl <br /> the Department orSafayand Pmfcvional Sei— Pesonul information yon provide may be used for secovdary (03/� <br /> wrdance with the Pdvne Law.v. 151 U(m),stats. Gw/I V40, <br /> lu Application Information-Please Print All Infonnotion <br /> PmpenY Owner's Same Pamela 36.4"'a 000 <br /> L.oce retiemwS Or3000 <br /> rwntr otrrr.Mnding Addnwa reovrnr Lonnan <br /> /1(170 Tho As ZN Go.tlnt_ <br /> C',slur "/.ip Code Phone Norther iA Seaton�6 <br /> (, :S/d,t G/.1 -4G(� /86/ 'mate) <br /> T��N. A ti 1:n® <br /> 1f 'fy sof Ituildin ((check all drat apply) l.mtt <br /> SUNh-ton Fame <br /> I ora Gamily rnvcuing-NnmlxrofR¢kaoins <br /> ❑lock 9 <br /> ❑Puh.'onmmrtnl-Dewe be Uxe Ll Cis,of <br /> CSM Number ❑ village of <br /> ❑State owned-Donibu Use �''fmm rr_f/d//"S <br /> 111.'I ype of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑ New Systein I ❑ Replaaement System K' T ...ullolding Tnnk aeplaecment Only ❑Other Modification to Fximiag System(explain) <br /> B. ❑ I'annit Renewal ❑ I'unvit Revision ❑CM1mtge of I'lumba ❑1'emmitTmnsleno New <br /> List Previous 1'ernd Number and Date Issued <br /> Retme P.epli . owner iii L10&2) S'S=/14$3 <br /> f, a of P(o%TS Sustem/Com onentlDerice: (Check all that a I[k) <br /> JZNon-Pressrai In(hound ❑ Piessursed lmGmund ❑ Atreal ❑ Mound?24 in of male soil ❑ stand<24 inofsuimble soil <br /> ❑ lloldingTunk ❑Other Dispersal Cmnponeat(exelatn) ❑Per-orae Devim("ah-0- <br /> V. <br /> "ah intV.Dns ers:drl'romment Area Information: <br /> Dutgo l'low(god) Uoign Soil Apphention Ratefglai Dish(Area Riq�intl[sQ Dispenul Vrn l'mpmedlst) SYsmm plcyadum <br /> VI.Tank Info Ca'sai in Total dof htanufacmrcr _ <br /> Gallo Callous Units le rj - <br /> NtwTan4s Fzi eTan4a _ 2 zs <br /> _ _ <br /> _ rV' - <br /> Sepal or l OULa Tnnk /BSO roSO / �nh'!/{r.-fo✓ '� <br /> IMaiupclooi <br /> \'I1.Responsibilnty Statement- I.the undersigned,aroma,res W nslbility far installation of the PDR"I'S shown on the uuaehed plans. <br /> Plural Name[Prtan Plumbers Sgnmure NIPNPR9Nurli Rusmees Pbone Number <br /> /C"G/G //o 0 le,n <br /> Plumbers Address(St ret,City.Star.zip Cada <br /> X7760 //-- � /✓1/'t5str� �.i 6ya`s3 <br /> �V}I IL ConnbdDc arlmenl Dse Onlr <br /> W Approval ❑ Disappmvml Prmnit fee Dute IwsuN lotting Ahem Si�mure <br /> s 3ZSo� -7 <br /> 0 Owner f ivrn Ronson for Uenial <br /> IS.Conditions of Approval/Reasons for Disapprmal <br /> fp P—loa-e Syj� O,n ek l 44- 6lon. di instiaez/-aprt, J1 l I�•. 1 \\v�/ D. <br /> 11 JUN 2 5 2014 <br /> loam mcamp4v pram nuir,l mem lad memn...i Coa . am.On ,a,,.nm le:emanXmat'w' oe In aizt <br /> 13URNETTCOUNTY <br /> ZONING <br /> SBD6399(RU313) <br />