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�c»a�r`r Counn <br /> Safety and Buildings Division )/ <br /> P ` 201 W.WasItinglun Ave.,P.O.Btn:7162 Seaiun ft—a N.ad er fm M tined m ler Cv.) <br /> PS_. Madison,WI 53707-7162 <br /> 3�58�z <br /> Sanitary Permit Application sm ra s Nnmb<` <br /> Ino—alare—ahSPS l33?i(d).Wiz.Adm.Code,submissionofmiarammthe appruizre�verrwmmiwait 2z939 <br /> rc9uimd PrimmabmininSamniwyprnni� Note:Applienionf Forstale-oxvd FOWlS are sArrtruedb <br /> lrjesl Address(ifditferenl thin mailing address) <br /> the Depamnent of SSfM"od Praf iorai Servies. (l X.)l iNamation yw provide may be usW fws�dary <br /> IuseeintionInfovdbio Priv tan.s.li wpgm),Sia¢ //^ eo / /� <br /> A Application lnrormation-Please Print All lnformatiov fJ0 `� ` �[C <br /> Prolxm is Name r � � Parcel: <br /> Property Omer'.Math 4 reu Pyne London <br /> 4/ (l ve Gx„.Ln. 3 <br /> Cirv- r Zip Code Phmreotaebu <br /> Mere W, '/.. Seoinn <br /> 2-1 <br /> Wh; lk „o (eimleone <br /> T YO N: R_(�E� <br /> ILT'ypc of Building(ekeek ail iha[apply) Latg <br /> Iorl Family Dnelline-Nualerof Bedrooms Z SuMmster Name <br /> Black k <br /> ❑Public/Commereul-Describe Us, D City of <br /> ❑Seam Oxned-Descnb<Use CSMNmabo DVitUge of <br /> §2Toxnof (2'AkklaIj <br /> 111.TypeofPermit (CM1cck onlyone hom ov line A. Cvmple[alioeffifappikable) - - -A. ONen System ITReplacemeat System DTream.mt/lmWing Tank RePlaeem....Only D ale,Mndien"ort E zona Sort—(e'wr,) <br /> n. Cl N.il Renexal ❑Permit Revision OChenge ornamWm ❑Permit T�mNezr Lm Pmvmuv 1`1n11 Numlef and Dare 1e <br /> Before Expiration Ox'rcr <br /> IV.Tvpe of POIM 5astem(Com onev PDerice: (Cheek an mora lv) <br /> fyNon-Pfesaurltt la-Gourd D ProamvM la-Gromd ❑At-Grade ❑Maml?p<in.ofsdmWesvil OMourt1<24inofsuilablezoii <br /> OHoidin.TanA ❑Older Uisperzal Campmrmt{ekpiain) ❑Prevraknem pcvitt(eaplainl <br /> V. Dis erzaUfrcatment Area Informalian: <br /> ncsien Flon(gpd) Desien Soil Appiirmmn RatHepdsU Disposal Area RepuirtAfsl) Dispersal Arta Pmpesesl(zl) Srsem desertion <br /> ou y7-8 1W,el 911616 <br /> VL Tankinfo Capacity- Taal hof blemofzcnucr <br /> Gallorn Gallao Unity _ ` <br /> •, <br /> Sep'icorliolding Turk QV Qu <br /> ) Ikaing gwnber � <br /> VII.RespousibiliKStatement-1,the vnderfy^oeq—sesvea uvUAy fer:etta fieuefflee POWI'S,bm.ow rhe+un<ped Mnn <br /> Plu rs Name(Prior) Plumhh Sigr home MPMPRS 5195 !NmnW BuMore, m <br /> ess More,N" ber <br /> e of ter 7!b 866 <br /> Phimber's Addr<s(smsr.ctv.Sme,ZinC ) /V�i <br /> zlz& I'q- I d5TP/Ld S��Q <br /> V IL Coun Wf a ar[mevt Use Oniv - <br /> Appmved ❑Dwppmved Prrmit Ftt 6^ 1 lad lmrirg t <br /> ❑O.assr Gvm Reamn for Omial <br /> IS.Conditions of ApprwnVReaanvs for Disapproval �j <br /> wm w<omrael<nGos rorr�vannm.ae eamm�ro ue evov-oary ve wPmeal lesmaa a rn.D:ame Im acre <br /> SBD-6393 M 11/11) <br />