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n. <br /> Safety and Buildings Division n ' <br /> 'Y' <br /> 0 S ;\ 201 W.Washington Ave.,P.O.Box cove <br /> 7162 Smoury Pemtit Numxr J.be filled in M Cu.7 <br /> Madison.WI 53707-7162 <br /> Sanitary Permit Application San/"�"° °"" <br /> In accordance with SM 3832421,Wis Adm.Code,suMnision of Ni,(mm m the a opnale B^sx-^a"nam veil C.p�.�p/ IJIN <br /> 6 requires pnw m obmini.g a—ury pewit Nor,:ApDlimriurt(fa sou %ocd JX)U9 S are nbmun Pmjcct Address lifditl'erem him mmi,,nmress) <br /> the Ikpanmem of Safen'and PalesiotW genies. Pcuunal son, ion y'on provide may M ivad for sttwdary <br /> acwNancewimm Priya taw. in!AllU m sun. 5 / /J/ /1' <br /> L A lintion lnformmion-Please Priol All lnformalion U k <br /> rrwDcm Na Pamcltl ozo3G1 •10-17-09'5 oS paB-clr2 <br /> / C� 3 036y9�90 00 <br /> Ikoperty(hsmr's -Iitg Add Propnly l.owtwn <br /> l P , v e N. Go„.Lot� <br /> G/�}/afSul< zziipccoo/sic Plum Numbe, Y., V., Section sf� <br /> T -1/0 N: R 1 /irclE on<l/ <br /> II.1ypc ofluildine(check all char appl)) Iata <br /> PI ore Form),(1Tvcding-Numberoflidreums Z Subdivision Name <br /> nock 0 <br /> D Public/Commercial-Describe Um <br /> ❑City of <br /> C]Scam Owned-Dmcnbe Use CSM Nombcr ❑Vdiagear <br /> @(iowmof UNi0A1 <br /> 111.1ype of Permit: (Check only one box on line A. Complete line B if applicable) <br /> \' ❑ Ne.S,tem DReomenem System )rTfotmmUNolding Tmk Replacement Only ❑OUrrMWiholion to Listing System(explain) <br /> R. ❑ Permit Renewal D Femur Revision ❑Chem,,of Plumber ❑Pewit Tumfn m Ness List Ptevmoo Pews Numher and Date Issued <br /> ucimc Fs'i.m. - Dwaa, 40692 C//o26911 r83 <br /> I\'.'fs cof PO\\TS brstcm/Com onenUDevi<e (Che<kallthm. I, <br /> D Non-Pressurimd IrvGrnmxl ❑ Prcssmixcd In-Ground D At-Gmdc ❑Mound>24 in.ofsmublesoil 0 Mood<24 in nf,.,wwe mil <br /> DIIolding Tank ❑Other llispersal ComPanent(explain) ❑Ptramlmem De,iee(exPhtm) <br /> V.Dix ctsalyl'rcatmem Arca Information: <br /> Design Filo”ffggpd) Design Snil Applicmion RaingPdc) Dispersal Ann Restudied(sl) Dispersal Aro Proposed W) System Flevation <br /> 7 k <br /> P1.Yank Info Capacity in TailManufamucr <br /> NnTanks <br /> Gallom Galhn Unin - <br /> 74 <br /> ' Eaiuitg TWa C u _ n _ <br /> Seyticw lblYmFTankoo A ) <br /> Dmiug<emM V <br /> CII.Respnnsibilin'Stvtement- I,the undeniged.assn Iroosibiliry for imusarioa oftae M%%\ S shown an the atu<hed pia- <br /> PI Name lF'rinU %um s trop^ MP/MI'RS Numbm Rm nes l'M1one NumMr <br /> �tf 51951 �/5 �66�70 <br /> Plumber's Adress(S.1 Co, Sum.ZtpCy�1� <br /> Z712o Til t7e^/ Mrd WeL5lel W,54 4 <br /> �VIll.C"unu/De artnm.1 Use Only <br /> /u A—,od <br /> 00 <br /> UissDDrovd flanit FttCp� Dye Issued Issuing �gnture <br /> D Donner Given keaaon our Denim S '75 e ✓Z� d+G� � <br /> IN.Cnpdilions oL\pproval/Reasons for Disapprosal <br /> 14,14. RI.p'dce.nd.vf a�Wf font (Jlle( TdC. szi&� r.k. <br /> S;I AAA by Cal(ni. &naon cP VIV S3 loih"in Sa.FnLk ,56111. <br /> .,cam n r.mdrn Main ro.nae a»nn.M comm m chermmtr rF w p,r-.Ma Wn a m.11 immes i.uza <br /> SBD-6398(R. 11/11) <br />