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i Safety aid Buildings Division Dane R.Fl <br /> 201 W.Wachl gton Ave.,P.O.Box 7162 So,;my prermit*.her(a be frlkd'm by Co <br /> Magsbn.WI 53707-7162 <br /> .�� / 3—,zvee —c20o1.6� <br /> Sanitary Permit Application Doe Tmaoimr Number <br /> to accords=with SPS 313.21(2).Win Mm.Code,submission Odds form maw appropriate xovamvnel oak <br /> is required prix a oblrnioe.solitary permit.Note Application forms forsomeoawhImoed POWTS-e slbmbld to Project Addles(if different del makiete oddness <br /> die Maces orSo e r mud Pathologist Berme.Personal la <br /> Shier. tr V M <br /> ompose a.eerrkme with the Privacy Law,s Iso4(I xmL Sss. R e� 1 �[',Jl Hwy 73 <br /> L Appliwtlos lnfotmdee-Please hint All lsfatioadoo <br /> Property Omer s Name AUG a S 1 a <br /> Blaine Haugen 0712-211-7626-0 <br /> Property Owner's Maims Address public Health MDC �p ty Location <br /> P.O.Box 563 Environmental Health Govt Lot <br /> City,Stale Zip Code Pile Norther SE If, NE 1G.semen 21 <br /> Sun Prairie,WI 53590 T 7 N R 12( ereeser)W <br /> II.Type or Bundles(cheek MI that apply) Lot I <br /> ®I a 2 Family Dwelling-Number of Bedrooms 5 Subdivision Name <br /> Block <br /> ❑PubeeCnnnterell-Desarbe We ❑City or <br /> ❑SI.1e Owed-Describe Use <br /> CS Nether ❑Village of <br /> ®Town or Deerfield <br /> Ill.Type of Penult:(Cheek only one box ou Roe A-Complete Ilse B If applicable) <br /> A. SI New System ❑Replacement System ❑Trnorerlmoldeg Tee Replacement Only ❑Other Modirieloe to Editing System imolai.) <br /> B. ❑Permit Ree.nl ❑Pernik Revision ❑clop orrimaxe ❑Ruh Transfer m New Us/RC1'iots P rmit"umber mud Due bait <br /> Before Expi od e. Owner <br /> IV.Type or POWTS Syshs/Component/Delia=(Cheek all that apply) <br /> NonPrmwized la-Corned 0 Pressurised levGmurd ❑A4Cbade ❑Mud;24 in.of meltable sell ❑Mound<24 it.of suitable soil <br /> ❑Holding Took ❑Oder Disposal C®pone,leopkin) ❑Preueameel Device(cop Wet <br /> V.Dlsperavrremtmeat Aron Infermatlos: <br /> Dodge Plow(had) De*Soil Applksioa RmdgpdeI Diepeal Arm Required psi) Disposal Am Proposed(sit) Syslon Mention <br /> 750 0.5 1500 1500 95.1,95.5,95.9,96.3,96,7' <br /> VI.Talc Info Capacity it Tool I of Manufiouer <br /> Gallen Wilms tilts ��k7 <br /> New This F Woe/Tel 1 9 11 <br /> u av I=O a. <br /> spnem/Wig Toot 1000/600 1600 1 Crest x <br /> Deft aster 800 800 1 Crest x <br /> en.Reopoesi6iity Statement-I,the undersigned, rnpomPoBSy 6.histamine.Oda POWTS shown on the attached pass. <br /> Phmuher's Mom(Rim) Sipsure MWMPRS Number Budoma Phone Number <br /> Tru6,t5 ( S:z,e l zu -,'v/ 3D!11 <br /> Phmrber's Address 15,04 City.Sore,ZipCode) <br /> N7$ta'[ etc/D gekvi/4 L_j. 534)$ <br /> VIII.Coeoty/Departmeni Use Only <br /> ❑Approved El Disapproved Panel FFeee/ Omer Lid issuing App Signature <br /> ❑Owner Creep Rent he Denial S <br /> IX.Condition of ApprovebReasms for Disapproval <br /> Mach io atepkte plan,fm the amen.d melt a the Cooly ask,a Ppa.at km Ito.a Id r IIaem Is its <br /> SBD-6)95(R.1111 1) <br />