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Cam Dane <br /> ! TAr., Safely and Buildings llolsion <br /> 440.,.'`pi 201 W.Washington Ave.,P.O.Box 7162 snowy Permit Number(o be bed in by Co.) <br /> � � �sfi Madison,WI 53707-7162 <br /> SCANNED 13-v°'(0- °° 1' t <br /> Sanitary Permit Appli€ntinn State Trimmed=Number <br /> la aaordma with SPS 31325(2).Wis.Ada Code.at minion of this fxot at the eppopeisle gocanmaod ash <br /> is reached prior b obtaining•sentry permit Ram Appemtim Rims fee state-owned POWYS ere submitted to Prat Address(if different than maniac eddies) <br /> the Department of Safety nod Professional Settles Pascual hnRbsuba you provide a1q be used for secondary <br /> Purposes b ecwrdenm with de Privacy taw,s.15.04(1 xml.Sias. R E _I I V E Q Getz Road <br /> I. Information-Please Print A6Information <br /> Owner's None )'wed l <br /> Thomas&Tamarin Beard MAY 0 8 /0607-062-0017-0 <br /> Property Owner's Wiring Address Property laeatbc <br /> 306 S.First Street Public Health MDC Govt.Lot <br /> City See Al • Em»AgeMitigelyealth <br /> 4/5W 'k, nnN Y,.section 6 <br /> Mt Horeb,WI "2 778-62 T 6 (`'imleoee) <br /> IL Type of Bulking(cheek ii that apply) ion 0 N a 7 E or W <br /> 51 Ior 2P emnyDhnetliag-NmberofBedrooms t 7 X016 <br /> . Bleakr i Oak Glen <br /> ❑Rmbee/c,mnaeW-Desarle Use ❑over • <br /> ❑State Ownd-Deanberlse (StdNmber ❑V(Ibgeof <br /> IS Town or Springdale <br /> Ilf.Type of Permit:(Cheek may one box on Rae A.Complete ran B If applicable) <br /> A. r2New System ❑Replem.em System ❑TrmeewMokdng Talk Repiseme t Only ❑Other Modification to Basting System(eepldn) <br /> 8. ❑Permit Renewal ❑Pena Reekim ❑(hsapr of Pb mbel ❑Perch Transfer to New Lisi Prc ions Peel Pbmba nod Date Issued <br /> Defoe Expkuim Owns _ <br /> W.Type of KIWIS SystetmfCamponent (Cheek al that apply)i�'` ■ ■ <br /> ❑Non-Pressurized -GLw d ❑Pressurizdlo.Cerouttd ❑At-Grade B'Mooed>24lo.ofsmitsblest1 ❑Nord<24 fa.°imitablesog <br /> ❑Holding Teak ❑Other Disposal Component(esplein) // ❑Pw(reumea Device(explain) <br /> V.DlepersaVrrenlment Area Information: <br /> Desipl Hot(gpd) Design Soil Apdkniaa Ratggpdsn Dtspasol Area Mildred-- (al) Dispersal Area Proposal(sl) Sysian Smoke' <br /> 600 1�(- k I )Q( /,0oc I 1j313 I 100.5' <br /> VI.Tank late f is r N il i <br /> u1 k <br /> New Trott PiBaer Tots $ 3 j B <br /> Cu bMi3 ra CO E <br /> Sqa"rl leeT"ak 700/550 1250 1 Crest x <br /> Dosing Chamber 750 750 1 Crest x <br /> VII.Responsibility Statement-I,the undersigned,=we responsibility for butaAallan of the rOWrS shown on the attached plans <br /> Plmeer's Name(Print) P er's Si t c MPlMPRS Number Business Phone Number <br /> � <br /> i(2w(4% e /(x72 o82. L/74-30/Li <br /> Plmba's Addicts(Steen.O ,Slate.ZIP Code) -.. ...,-......... .. <br /> /1?79o5 C 0 Bel/ems!/le' l.� <br /> V Use Only / �/ s. <br /> Pennit Fee vry'd ❑Owner Oven Rauon for Doniol S / ,, _ J -~7 , <br /> IX.Conditions of ApprevaURemons for Disapproval <br /> Alteta Is complete pins far tea signs nod admit l lee Cook/wt.m paper aN lea IMa a to s 11 twins le dw <br /> SBD-6398(R.11/11) <br />