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<.:�a"'Fo\ Central
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<br /> V, Safety and BuId ngs Division u✓n Q'�/"
<br /> r � ,-`:: 201 W, Washington Ave., P.O. Box 1162 Somme Permit Nnmberltabeunedinbyeo)
<br /> Z �! Madison,Wl 53707-7162
<br /> 55 8 9 4-9
<br /> , ,
<br /> Smro-I mnsac,ion Number
<br /> Sanitary Permit Application 3 2
<br /> In aecoNa...wid,SPS 3931 qI)-N'in.Adm.cite.s.bmixa nt of this form m mm
<br /> the ap,,.,I.ta In,eental ant,
<br /> is reyui redpnnh.obtaining a sanitary arm". N.ts.Apphc,amformsfmsmre-mc Id POLARS ere sabmined,a Pu,jea Adaress(JaitT rem than mailing address)
<br /> the Ihpanmcnt of sal'ay and Professiorel Servies. Persanal Infermatinnyou prm9dc map he mad for secondar,iticirmses
<br /> Ln
<br /> accordance with the Privacy Lm..s. 150IM(m),stats '7a6D/7374 /dlC�', 17JI
<br /> L :\ lirrtian Name
<br /> atinn-19vasa Prim,\II Inh,rmatinn
<br /> Vropem Omer i NNa a Ym<al p p7-o2001-mO'el2
<br /> %/erzl Ca» 3�oI o�.0 - 11337 - os70a
<br /> Pn,pett 0,%re,r s Mailing Address Propene lawmion
<br /> 7akoz/ W. 7«f, S'A Gia, Lot
<br /> Cirv.state %ip ColicPhane Number„ 5 Section 33
<br /> S} LOudJ ID.✓k rv7ltl Ss'r76 NR mle ones
<br /> l 40 . ria e are
<br /> II.1,pc of Bnildm.(eherk all that apple) Lata
<br /> tt 1 or 2 Feard,Dwdlina-Number of Redmome suW ivis er,Name
<br /> Blocks
<br /> QPublidCommemlul-Describe Uxi- amt.,�f- �n �_d ❑Cin-of
<br /> ❑State Owed-fhsc,ibe Use CSM Number ❑ village of
<br /> y�lu„nof Ort/c
<br /> III."Ib,cof Permit (Cheel�k••onk one baa nn linc A. C-1-11111cline It irapplicahla)
<br /> A ❑ New system p,Replaement system Dl,aarmonilHuld ins Tank Replacement Onlc QOtherxAnniammn In Listing Ssrem(eaplam)
<br /> R. ❑ Permit Renewal ❑ Permit Revision D Cher,of Plfi"nNew List Precious Permit Sumter and Dare Issued
<br /> Befare erpim,lnn o„tre 5 32 Z.3 8 13 4DV. 09
<br /> I\ "It,e of I'll\\'ls Scslnntlfnm mnentlUc.ice (ched:mthinu, Ic
<br /> D NnrtPressnd:ea I.-Gromed JN Vressurired In-Ground D At Grade D hluuod 1 U in.of vanish e.rsil D Mimed 124 m.Ofsui.blc roil
<br /> ❑ Ilrldine'lank D Other Dapeaul Cmarii mleaplairp D Pren,,rinern Device(ecplam)
<br /> \. Dls,areallfnatment Arca Information:
<br /> Design Plow spar fl.nsign Sail Application Rate(gpll) Dispersal Area Rey.ir,d lsp Dispervl Area VmposdlsD S""c,Elavmiun
<br /> 79/3 • 7 1/91/6 Y968 9a.
<br /> C'I.'1 ank Info Capacity in Tnml sof Manafazmrcr
<br /> Gallons Gallons Units -
<br /> N-Treks E....inb Tants - _ _
<br /> 5eyuc ar Xoleing Tank /per 7S0 310 H)SO ,3 �, .rft✓ .. _
<br /> Dre—Chamber _/CCo /-7J0 17s0 3 N'11T•'
<br /> \'I I.Res po n s i hi It to Sia tem Int- I,the andrr.i_ned,a.wme rrspomi hair,rite inem nation a the PUN"I N how In n the attached flame.
<br /> Plumber s Name(Print) Filtrate,i scamnae 11PIMPRS Number tarmee,Phone Number
<br /> //r,
<br /> rlamne,s Aadres,Isveet ci,y,smrc,zip n,ae)
<br /> \"III.Courit0 I anthem U,e Onl,
<br /> Approved D D6......ed Permit vee Dwa Issued Man , ge ecanne
<br /> ❑O,mer Ohen Reason for Urniul
<br /> 325Ad 13 Ma>' 13
<br /> I.C.Condition,of Appmv allllea,nns for Di,n Pprraal
<br /> {�e v151oto T, an/- refsSw -e sF, SAf11/airy �crm�t 532 38. 1 .c.-i /irarh><i'r+N
<br /> I 414 was not InsEstUtl vf+Aer Qrw-ovs eirwlt, anof locebfm- cha%.;,4, along wl{h iril&
<br /> ICSSe j ons•
<br /> .aura ra eamptry plan,mr In,,,,rcm and,al,mh m ma enam,..mr an raP.e am In,nn,n s an 11 mrne,m,ite
<br /> sllDfii9s(R. 11/I 11
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