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RECE I <br /> IpolrB_._SOC..,__ DxY:_ Ci11y S_ <br /> r JAN 11 ZO 6 ` 1 wo E We6itiflpta+t Avs yPeanut.Number(to tie hscd m by - <br /> '; -. ' 12.0 Boa 7 ttc2 <br /> /�, blaaiwR,WI s37a7=7162 <br /> ,2-t)(t.- 0001 <br /> ",; Public Health MD' c. <br /> �4� ...- State Traas,caouNam r <br /> `� ' ' Application <br /> Sanitary rlAta �vM,1tU'411:t9t-Wiit � ��- <br /> bi oerosd e C alth$ S 3$3.21(2),Wis.Aden"Code,subuti x t of t foots to the apprap g'• eet:A dress(,T'tif(ttent than maibngi nd e3s) <br /> c Note:'Application bonas.lnr state-owned POWTS are tad,ttitts4 t° 1 / <br /> to required prior f0 Safety ai a,v lessi'penult. be wed Cot'stocioier1` /�(/J/ <br /> the Department of Safety aid Ftaihuiosri Servioes..Pw'so�{.S�uan�vou.prmiide°maY —` <br /> .sea(a aeoordaor�c with the Pirko law s.ISM L.-'-, --- ,//_�..- <br /> par-- <br /> �, ,■ cadonlnform�►elon-Pleeso•Yrtnt:Alliniu=mntiaa O�((�O�_�73`��2 — <br /> p�pet-r Comer's N`a_, r r 1 _-/ ------- <br /> °J r�.Sc2/V /1 --_ Property Lc�olion <br /> maeny sa se Adder /to K r L _�, Goyt.Lo1 <br /> 0 ,lam fr/ v(.J G I T J $.1 ____./.. 7 /. Sep tio�t <br /> - Zip Cone, ._ Phone Number �j ! 03 --- , eT <br /> City.Stave W •.-� '"' 6 0 vl(_cz / T N: R • - ) <br /> (check all that apply) Subiii ;:iuo NAUta <br /> t Via bf'BltNd1RB 3 Qr � ILL <br /> °7711'' f BedrMvss / 1--.1,��rC7� _. ^j am,..., <br /> •�t-or 2 Fimiq� <br /> Dwstiiog Number Or tlwk# �— <br /> ❑City of <br /> (]PubikiCout+ ilt-DetenlR Ilse_--_ -_-___- ❑Y iitige of <br /> • !. Turnhrr <br /> ❑State Owaed-Otsoribe Doe'__--- <br /> Cheek oul one box on lint A. Compete tine U tt applicable) <br /> ___- - - Of p ,Monte on to Extitm¢System t imn) <br /> I[i.'[ypeogyeriNit: ( Y ____. T Re¢lacct,clntM'.y i 0-Apv� `I <br /> 0 Rcpla.ernlltt S}strn 0 TreilutcatlEckliog pp <br /> lill ❑'New S�simt List prer�ous Permit Nuinbcr an4 Dote txsaed <br /> CbnaBeofi}4tstbor flflennit"1'rausRr:u2titw . /'O '1 5 /203/ <br /> Q eatiAeaewal o Perron Rerisava •ill aeWie Etp+ -� <br /> IT. of 1'Oatclu/C o, ,> DRViCe: Cheek�It IhAt a 1 _ <br /> - ss9awiztd[n-4raad 0 pse.,s urired(N a(round At-Ge a 0i-. <br /> M- <br /> ou uO-_?-:2 A i <br /> a.orwicehlosol © <br /> Mound c 24 ► o suitable nail <br /> ] <br /> 0 Holdia{Tack OthacDuPea*t Px ,f_ .,I <YrtmtmrJi.MirS (zDlt!o - <br /> • <br /> _. . <br /> _ <br /> -- -== �"_- `:.;' . <br /> •Y. ull sat/Treatment Ai rsfa on t ��� <br /> Dasb* ow(11 •) Derigu Soli pherekotsi cD .; xs, R;quired(¢ Dimersa (- 'System ev on � <br /> � 7 JO l A • 96.61 r �be 2 .. <br /> -C- <br /> VI.Tank into CorockY it Total' B of Awu$ctirrr <br /> Osuans Gtillurts iJaits &a Ii gli <br /> Now 8tdsiia`Tuxs' • <br /> _ VA iv..xNotuLi 4snt _—_-r------- ,,• i 10. _____e_s_-__e..._:______... <br /> DeaUy Chula., <br /> Ehc dadcn p.. �---- MP/rm o the attached <br /> 7lans._sa Phen Ti Q <br /> linitnlseCS t ., .,c rt9 u5ibid for 1i 6tailatlon 0;the POWTS gbesvn on the vouched plans. COQ Q <br /> VII.Ara 4010 l Statement-I,_____ iant r• iignat:ue ao� /�� <br /> Plumber',Addaeess(Shat.Cay.State;Zip Cola) ‘A rm et i eeeu W---4--- ` - <br /> f,C outs /De•nrtmt nt lilt OM` <br /> . <br /> P Fee Data tared 1 B Twinge <br /> ❑AMMO DteapFmrea S / <br /> ' <br /> . . _ <br /> Owner Give*Reast',a for Oeoiat ' <br /> 1X.Conditions of Appro l VRtasons Ior Disepp a <br /> oval <br /> ��. o I 7 7 „at ✓ <br /> --A+akwraoapF!+e*hosier tM Eti - i jtr a waliw i tR.i ,wt Nilhsnl <br /> a t1aChd4 1 <br /> SBD b3i18(R. . <br />