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Safety and Buildings Division 0(N <br /> .$ 0 201 W.Weatdnglon Ave.,P.O.Bax 7162 -§anima Permit Number I.be pled in b Co.) <br /> i MSPS' F) Madmon,WI 53707-7162 y <br /> Sanitary Permit Application Son/T�aysa�.n Numb�f/ff� A <br /> in accordance wilM1 SPS 393.2R2),Wis.Adm_Coda,submission ofNisf rode apprgxule govervnenW coil (/WfE'� /'u�UIP <br /> s re9airM prior ro Safety <br /> nd Pnoarrpcnnir j, personal <br /> iigra fu,.,mcdco POW TS are subrANedm ProjectAddress(ifdifierem shun mailing address r <br /> inc peparzment ofarcep'ata Prnf vi imul S',15 Persmd ildomulwn you provae mar be umi f ary <br /> lir resin azcoNwcesvittitu Pm Ie Printill(I a), <br /> p Application lnine tion-Please Print All lnformafion <br /> Pr.pcm0 'Name Pamelgo7-o10�p-yoy6'35-5 - - <br /> i emck DsRR(cK,-rAM 1 Re s e Tdst 1*2 7pa <br /> VmpcnY arfl�rcr'�://�,lailirg Ad Pm l.oati.n <br /> v I •`�e -� V� property <br /> I <br /> City,Stale 1 / Zii'C[ooh, PM1are Namba K. V.., Section <br /> �1�S <br /> /IJP�.k) Id ,N <br /> It.'I ype of Building(check all that apply) .¢, Lot T <br /> �Ior?Family Uvelline-Nwnber of Bedr.oms / Subdivision Nara,Plo k a <br /> ❑Public(Commercial-Demnbe Use ❑aty nr <br /> ❑Smta OwMd-Describe Use CSMNumbe ❑ Villa&of <br /> VToavnpf <br /> III.Type of Permie (Check only one bas on line A. Complete line B if applicable) <br /> A_ DNi,.vS- tem gRelamaneaSsarn DTreamraw6olam Tarek <br /> )s y p Y g Replacemem Only ❑plM Modificeuon n, jairg System(explain) <br /> B. DFe,ong Renewal D Permit Revision DCT ,ofPl.mber ❑Pamir TmmfamNeav List Ptcarea Petmit nintiareM DalelssuN <br /> Before Expiration - Duret <br /> RC T'Pc of POWYS Scstera Com .... Dnrica: (Cbeekalith la Iv <br /> �'N.n-Ptesudud lmG..M DPreaorim l-n oad DAt-Gado DMaud?2¢i. ifatiebiesoil 11Moad124ln..fsoiab1emi1 <br /> ❑ holding Tank ❑ONa Dispersal Component(crpiain) D Prercawent Device(eapli in) <br /> V. Dis rsal/rrea tment Area loformation: <br /> Uesien Flov(gpd) Desien SndA on Rme(_epdst) Disposal Arm Requ'ved(sn p iArca vtem Elerahon <br /> vso �i1 yam, quo(at, s.a <br /> ss <br /> vi.'rank Info CapanTotal hof Mawfxrorer <br /> Gallom Gateau Units _ c <br /> Nex'Tv�4s Hieing Tmh <br /> V - G <br /> S.ytie orNdJing Tana o /dyr� � r yif <br /> CosinSChamb> �l�l/ t/-V wt�1/ <br /> VII.Responsibility Statement-1,the undersigned,assume respomibul hr imapati...f the POW4S shwa oa the arbched plans <br /> Plu is Name(P/tintJ plum iyutme KIP PRSNumba Bxoocxx Phone Number <br /> 0�q er l SlfSl/ 7/� 7a <br /> plumber's Address(Sneel,City.Sure,Zip C 7 <br /> 191E Count'/De arimeot Use Onlr <br /> RApPtovM I O D,:7ve Permit Fee lAte Issued Laui�g A core <br /> ❑ow„et tir Reasonfa Drnial Sr3e2'S®?ul8,June. 21113 <br /> IS.Conditions of 1pprovalfRessons for Disapproval <br /> ,roach m<omMne clam for Ne mrn.aM whnnro rXcow-.oh.n ppern.r I¢.Ma.a m:U iorbn in s'¢e <br /> SBD-6399 M I 1111) <br />