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/s \ Safetyntl Buildings Division V r..vn�-�"
<br /> g�;pS'ri 201 W. Washington Ave., P.O. Box 7162 sanlmD carni Numberllnh hn,d in ny Cal
<br /> P `( Madison,VJI 53707-7162 `"
<br /> '•i,• li ,Si i���
<br /> Sanitary Permit Application stale IImIlrltnn a°'tp",
<br /> m ace d to
<br /> S owning -, I the pp P 't g m t l 1
<br /> rtq d p- bun b t _pe t t :ApplicationlImmolation1 1 s' d PON ID b '.d t Vrolea ddJrssl-I JIIuam Ihan mailing adore.+)
<br /> the IXpartmml of Safety nJ Yrofessiorul 5 ry s. Pewnall you pm.id may b<uud for - ,nMan ,pol33
<br /> xs in rx,mdance nllh the Privaolase,s. I i 04I1 X Inti.Stints
<br /> 1. kpilIMinor In formation-Flea,, Pr int A" In ho /•,/H(Y va.�Aa+) �'
<br /> Ympeny owner's urineo /) O�of}d4/ &3SJlS3Sl
<br /> 0 Pit) JA
<br /> Property Qvi s Mailing Address � Property'Lmnom
<br /> G 63v .574 ,C,/L CJ �/ . Lot_
<br /> C."Sime zipcoJ, Phone;ooNr Z. . Sec gS
<br /> [mo Lali '1-n A/ SSQIu —' 1`ir,l,unci
<br /> T�/ N. R1(�li mr�
<br /> fcpa of l3uilJin�(check all thin:gtpld Lot.
<br /> Iur2I'nmilyD„ellltly-Numbtt ofb'dioona �3� S ubdi.isiun p'umc
<br /> Blovk= R h 'P
<br /> ❑Publirocmin inial-Describe Use El 0,of
<br /> CS.\I NumMr ❑ Villugeof
<br /> ❑Slat,O,.ncd-Dcscrib,1W 3.S
<br /> IIL'I,i I,....it: ((:heckonl,nne hn\on lirr n. ComplHa line It ifappfirallle)
<br /> \- ❑ No.Soni im Replacemenl System D iemmenml tial d in¢Tank Repla:ement Only ❑Otbcr AImi lication mlixist in-S,sl,In(a,pl...I
<br /> B. ❑Permit Rema„a1 ❑ P,mo,Rr,Won ❑ Change or Plumber ❑1'mmlt'I runsL-rmsr,r l,'tP`r/,'lo�m�Prrmil Number�aod Dae I....i
<br /> Bef n,F..Piration O„ner a_ (06255 15-
<br /> IN. I ,,,
<br /> IIN.'I'c,,ofl'O\\"6 S\+t,mlCnm nmentll)r.irr: Check vll th:Rut I.) 033-
<br /> y9Non.Prtamiztllinemrlw ❑ Proeurl,,d In-0nwnl ❑ At-Grade ❑ mound I ZI in ,t otlblcsoil ❑ 6lound 12l lo_uYsuiuble soil
<br />.p ❑ Holding Tank Cl Other Dieprml Com,oxpI Rcploinl ❑Pr...-mem uv"',("Plinio)
<br /> \".Di. anal/frcvtmcnl.krnt Inform..lin.:
<br /> Desan Flo,:(ePb D,sign Soil Application R,I (mpd.t) DisF,r+al Area Required(st) Ilisprrsvl Brea Pmposcd 1st) Scxtem lilo-atior
<br /> NSo
<br /> \'I.I nnk Info co,,, iI, 'I'mul aof NanuNcmmr
<br /> Gallons Gallons Um,
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<br /> .I- 7-is E\isrinMTanrr
<br /> .L
<br /> s.micmlwldineranl: /ps0 //00 I .L'aw
<br /> Urine Clwmbn
<br /> \”11,12r+pnmihilitc lo.,In nt- Llh nnl...ir dJ ..+.winempnn+ibilin fnr i-WiLow.atIM1e PONT?+ho+,n on IM1eol.,rhi,c plan+.
<br /> PlunNer's Nem,IPflan Pl�mhel'+gl=nutur AIP'JIPRS Number Buamcs Phone Nontbcr
<br /> Zlcic //Po/ca i �G�`"C �d�Ffs/ 7rrSGG-4/s�
<br /> Plumber's dddm x(Sneer,Cin.Sti Zip GJq
<br /> 77G o H 35--
<br /> Gf/c6S{.� wr y s
<br /> V911.Cml.11/M ti rtntrnt line Onl,
<br /> AppnacJ ❑ UivppnneJ Permit Fe, Daal....d [ommp,%pent S.—on,
<br /> ❑tjo Gi.,n Rennin PorDenial
<br /> IS.Conditions oLgqum.nBReas.n.for Di.apprn.al
<br /> D ECEIVE
<br /> .Irwin tn,m...,i n,.Ne Mand A Name eo _ nnp nhaner nnnr.many V_.I
<br /> in
<br /> BURNM COUNW
<br /> SDD-6398(R. 11/11) ZONING
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