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::#2/"...-' _____._______-------_ <br /> JUL 24 2008 .:_iil . <br /> ,.o ,y�, $a and auadmp Divte o 1 courtly Dane <br /> -"'PubliCHalth MDC 201 W. tslungIonAve.,P.0.8ox7162 <br /> tl3i i l 11th ",�nlon,Wl 5370" 7162 3onibra P U be fI M by Co.) <br /> epaternene - ,f 7i` u 9u <br /> N. <br /> roe saes TaeeacIivn Number <br /> Sanitary Permit Application powrS 9024 <br /> l to seeerelince with e.Coew.t9.2I(2),Wit MIL Code.submiseine or this Ibttn to she sppropriste goverment& <br /> unit Is required prier to obtaining a sanity perMil Note:Application ferns for etete owlal POMS are Y'roient Address(if diirktent thmumnbet ed hveel <br /> submitted to the Dept of Commerce!• Peraoml intrenwitien you Provide nosy be used for ects+dory <br /> opens In Oriebience with tee rr; loww a A ,1 1C:/S+w_ 3854 Deerfield Road <br /> 1. Aa,Hattie*lafbrma ties-Please Print AilIstformadoo _ pssaaiN <br /> PTeperty O'ne s None <br /> Dale Miller 0711 241-9910-3 <br /> — <br /> Rvperry owner*,Mailing Addrein prate Location <br /> 3854 Deerfield Road t7ovt Lot <br /> CitY.awe Zip Code Theme Number - SE v., NE 'A Section 24_ <br /> Deerfield,WI 53531 764-1303 (+:ireleone) <br /> T. 7_--N. R 11I!orw <br /> Ill.Type or Building(cheek en dud apply) Let# " <br /> 2 Sabdlvlelen Nema <br /> t or 2 Paentlyiphht-NmnberetBedtiveee - L0.63 Acre Metes&Bounds <br /> Block$ <br /> - <br /> ❑Pubtiefiamleaclat-DeeaibeUee, .. --. ❑City of - <br /> CShtNulnbee 0 Witte' ..r <br /> Q O.,neet-De"'�Use GITeraeaof Cottage Grove <br /> in.Type of Penile. (Check e1t1p one box me IMe A. Complain the B if appliesbk) <br /> New System IS Replacement Syttern 0 Ttese entikleldingTeak Replacement Only ❑Othee Mo41fR+tion to Exiling System(efp1in) <br /> n List Pror us Permit Number and hub trued <br /> B. 0 Penult.RENOIR! 0 Permit Revision ❑Change of Member ❑Permit Tmertrto We* <br /> Beibres Expiration Owns <br /> IV,T. of POW'S S om • tlDevlcet Cheek all tkat a i' <br /> D Nee-P,v ee ed M-3rouod ❑Preano toed b-Oramd 0 AM3eade /Wound a 24 iw otsuhable soil ❑Mound a 241o.of eufable mil <br /> ❑%Arms Yank i]Other t]iapeteuI Component(explain) 0 piety: M Device(tatplain)� <br /> ■V.Disperealfirealoaeot Isdoraialleni <br /> Design ne w(ad) Des ign Suit Application R Mt(tpW) Dispersal Area Required jot) Dispersal Alta Prepoeed(if) 3ysm 5ea en <br /> 300 1 1.0 300 460 102.6' <br /> #Tet or Menut <br /> VI.Tank info � al Gallons Units xi 1 <br /> t.-7i irr Taub —ehth.taka _ g t§ 41i 1 e 1 I a <br /> ,- <br /> Smelter 1000 1000 1 Crest x <br /> unsieta** 600 600 1 _ Crest x .. <br /> vrt, • - . ,Ibill Statetaeet-I,the ender • • asseme teepees/NI ter iueteRetla lathe POW78 slemew a the attached plow. <br /> MFIMCRSNmnber tsneitlesPhoertNwnber <br /> P`J{ * ., ,e s J Jr C. fJ} ,_ 8":90:4) <br /> ij <br /> Plumber's Addiom(Street.City,Stele.Zip Cam) AO <br /> 1 , _ , ., / ,� ' (4. (,v ,,Inns fir:.. <br /> VIxI.Coen • h •*router! ere 0 _ rV�I <br /> Permit Fen; Del la r""l►� .TT+ �1 <br /> 'e- <br /> optimal 0DIrepproied s �► `��' � 'o 41 �%!y�',5��/ � �, <br /> ❑Owner Given Rawson for Denial <br /> IX.Condidant of Appro al/Reaaool fur Disapproval <br /> mem to melon.Mow ter the mows red tibia to the C.vely eery n paper wet tw MU e Aft e r i Iaefut la NU <br /> •D t3 Q WD , C K 43-a(47 <br /> SLID-6391(R.01/07)Velid dint 01/09 <br />