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Safe,,asW Buildings Division County <br /> 201 W.Washington Ave., P.O. Box 7161 f <br /> (S.COnsin Madison. WI 337M -1162 $Ia Address � <br /> Department of Commerpe 14U� 1 <br /> Sanitary Permit Application Smaory Permit Sumter3 0 <br /> N asord rid;aCGdw <br /> mod for soc Wlf.Adm.Code,persnml ildomudnn you provide <br /> m. be mod for sten ,n Privacv!aw.s13.0a(INm) �chock if Revision <br /> L Application Inforrrutlon-Plem Print AB ieformotioo <br /> Sure Plm 1.D.Numper - <br /> PMMM Owrcr's Name �O ) <br /> Parcel umbe <br /> Nr I"9 <br /> ew 012 2� 00 <br /> Pmpem rrcr i Mani,,ddaw Pro"i.Oea ton <br /> 06/o B7/' / E <br /> 4S <br /> ET <br /> olbr /5- E <br /> Cintic.Sua ZiP GadC PhoNumm Norther I. NKnber Hloct Numbe: <br /> Stbbnb ision Sunc CS31 Number <br /> If r M9 j �5'S076 Fa'J m-r n L• <br /> IL Type of BuBding(check all that apply) CC, <br /> I Or J Fevdty Dwelling-Number of Bee... <br /> 4 <br /> wnho,�eDmm<n.;a-D<—ne Use <br /> 17 Soo,Owned <br /> Heart:t R.- <br /> W. <br /> .mDI.Type Of Permit: (Check only one box on)lite A (vumbermg scheme for mternal me). Complete Bne B if appac2ble) <br /> A. 1VNew 2 �iteocenam Syitem J RcPlacmcK o! 6 ❑ AdNtloero For Co.,me <br /> S tt T 1 ONv Ecoun Svncm 1 <br /> B. ❑ Check if Savi Permit Number <br /> orY Pcmds PmviouslY Issued Dau IsKN I <br /> i <br /> IV.Type of Peredie (Check all that apply)(nounkring scheme is for imemal me) <br /> as C Non-Preuum<d I.Grmmd 210 M„..e 410 Sand Filar 30 C Constructed Weiland <br /> =0 Pressurized InLrn xd al 6f Holduly Tank 4 C Svylc Pau SI(]Drip lice <br /> O AOOnde 46❑Aerobic Trunn<n UNt 49 0 RacircNaunR JO G Omer <br /> V.DisperralfPrextsuent Area leformation: <br /> Design Row(ypd) Dis,,W Mn DoperiB Mea SOU.A,pik dnn Pemohdon liaa S 1 ! <br /> Requirtd Proposed Raa(Galy/pays/SQ.Fe Ysam Elrnd<v Final <br /> 1 (Min./Inch) i Eleeaden <br /> 300 _ I <br /> VI.TaNe Info Capacity in Tour Number Manufacm¢r Prefab Suc Sm1 Fiber � Plmtic <br /> Gv11oK Ga11oK Of Tanks ; Corcrea CJnswcad Glass <br /> Nn RriseK <br /> Tuer Inks <br /> Srydo ar Hokinr TanY zmQ 1 <br /> i De,ierk�+mxr I I / � w X i <br /> VH.RaPnmibility Statement- 1,the underogn<d,assurne roucesibuiev for imtanulon Of the PDw-rs sbo..n no Me attached Plans. <br /> Plumber's N;ne(Print) _ Plumber's si3Km:e I MPOdPRSNumbcr- 9uancss Phae Numece'” - - <br /> cµHazD ;✓.s I Z2S$S i X 13 866- 4�S7 <br /> lumbar':Addmn(SeeM Cory.Soa.Zip C W el -- <br /> z77 00 1+w 3s G/�ssrn .Wi . �4s9s <br /> V.I. Count /De atlmml Use iv I <br /> - Approved ❑ Dm",.-d Sariwr P-r ,,Fe:uccicdcs 0m Ona,,wr Dale Issued 1 g•nl Sigmmre Ob SomPs) <br /> Sur:mrye Frei-4�Bp,OD <br /> Owru Given <br /> ennwInidaL+earrt lr/``(v)--�'A^a•I�I� e <br /> D< ion � <br /> LY. Condillom of Appc.,.VRc...for Diaspproval <br /> 4w <br /> 'lig/"- S <br /> am <br /> A11.4mvla<Pw,a.n:Ce-m......rau,+rr.m On o."nw m,de.me s D come,m, <br /> SBD-6398 (R. OS/01) �N/NG"N7Y <br />