|
,
<br /> . ..
<br /> rt--"si,'It'.v., Industry Services Division County
<br /> • . ' cs,
<br /> i l'''''' .
<br /> 1400 0.W0i*gt.0 Alt. DA rte. _.
<br /> 1 .i,!.. ,..:., P.O.Box 7162 .SiniteryPernaNantber(to.be filleo in by Co)
<br /> hdadison,WI 53707-7162
<br /> ' -•' ' : "' '00 - '
<br /> •a- d'Ottl . -'---0i
<br /> .., .. .......14-....',....,..,-4!L"::___
<br /> Sanitary Permit Apiiiication .k State-TrattseedonNurnber‘ -
<br /> In accordance with S11:30341(2)iwiarAdpi.r.odi tiritottn of thislintit to the approprintetoirennitenral Unit-
<br /> Is required prickle ottairdintilanitariperrolt.tiotei.ApPlicatiOn$oryne for:state-owned POWTS are submitted to• Prole*Address(if-different than mailing address)
<br /> •.tlie DepartmentntSatety and Professional&vices,perwpal information you provide maybe nied."tott itedolideryr•,
<br /> : nurposes;ii amordance-with thePriViCY:Littv;ii.11.04(1)(in),•§tati:
<br /> . 1. AppirrariOn Information-Ploase Print AllInforniatiOn . 41.•_Y1-44r.4. • ti..
<br /> • -- -.. -_-„. 7: ' .
<br /> lirOptetY OWnitr'S Wald: ' - Parcel It - : - .
<br /> 1.-44t:& VH •W*1.sesiet.,t.i't,
<br /> Proper_ty0laner's Iviailing Address: . :prop ertytociatiOn
<br /> Wa74•56k•44k-Rible.1.0.t,, „ • • ,., .__ Govt.Lot
<br /> C/W..State Zip Code Phone Number SE y ' ', +. v Section
<br /> .4 -5--‘,%1 .4t: ,.
<br /> SO II,i 4. ..._, -71,1.3 1 It A ,_Tglicie.one)
<br /> v... a ,13.-ov
<br /> 11.Type of Building.(chaok all that apply) Lot*
<br /> Sivi ir
<br /> tdidiion-Ntoe
<br /> Ell oil-ktinilythvelling-114unter oftte6roorns: . .. -.130
<br /> -
<br /> -. Blockit. - -51....-ti-e& • -1ti:Af4 Oe(51,4+ 0-6•A
<br /> .0)tblietCotamerena- I-Desonljethe . , _ _ t"7""`
<br /> . .... - II'CitY0f
<br /> .
<br /> CSAiINusibet -• - . ' ' . El VIlitigeOt
<br /> 0 Strite Owned-Ire-scribe tits_
<br /> Town of V/WleeciM
<br /> • .
<br /> AL Typolet:Permit: (Check only one Sox on line& ConvietolipaD if apPlinabla).
<br /> * -R'.-/4ev.e.$ystein. 0 Rep. Ianmeat Systent- 0 Tresimen,V/Jolding Tank Rep liicernexit Only ;:El Other koelifieaticatto'Existing-System(explain)
<br /> B. 0 Permit Renewal .El Permititoisioti ,.. ..._ . . _ - • Ltst Previous Perinttirmtier and Date Issued
<br /> El Clump otrillInbt(:' Li ferng:AltaksIer10,,NeW - - 1,
<br /> Bi.fere txpiradon _
<br /> IV.Type otrowrs Systein/Component/DeVice: Whack all that 1poly)
<br /> EStos.;PresswitedIn-Giajnd 11 PitaSarizediti-Grouri4 ID At,Orade El Mound>24 itt otsnitable foil El:Mound.. 24.in,otoitable ea
<br /> 0 holding 1190arpsper#1:CtOpcnen;(explain) C PereatelitDevics(explain)
<br /> •_ ,.-- -- - - - - , •, • -, '• • . -• . •
<br /> V.Dist ormalllYesitment Area Informaliont
<br /> presiiii-Thiv Ova) Design:80il_ApPliestinnitate(,gpdst) Dispersal Area Requited(g) ',T/lsneriel"Aran.Preposed(4 . SystifitiReiTatIon-- " _" _1
<br /> 4 !.. *7:..5: ' l'13411c.:' .-7200i767=-1-4-i4F--7161:3A
<br /> •-.1.a..-Tokinfo 'Pall*ittin Total Cot -:
<br /> ... Manufhettirit ..,i
<br /> wad OallOnt Units . - ' o
<br /> 1 11 :11 a- .,. . ,4 .,' ..v,
<br /> ... N,v.rnalics. F4ting Tasks. - :5- VS :. 41 f -'. 1 XI
<br /> - ' 13.1,) - TE' ' .v. M: i.r.to-1 T".1:
<br /> Stlitic.e4oldhiglInit. ,traic.„:„. ..____ :u4-5A t • MExo5
<br /> •i -•,A, ,,
<br /> ..
<br /> ... , . ,
<br /> Dosing Chamber L-... 'f5ba -1' :f-, IMz
<br /> a,...s..— :.
<br /> „,. :.,
<br /> TILL Desponsilislity StateipePt-1',the tm.derilinedi assume responsibility for installs-den Of tlit-POWTS•shovat°lithe attiChett plans,
<br /> Plibiliti's-blinie•Oint) ,:Plumbeea*awe:, .! !,:),R11411tS.linnitier - Btliineis_Phiintailurober
<br /> • --: 'is-7C:- -- ' i;!!...A.a0.11 ..5. -' '':(.1,Atc-T.i.37:i
<br /> .Pharnber'S AildreSS(18tfeWeity,State,,Zip:COde). .
<br /> tf95t1. Cit.W,M1'^isti&l'. iciiskrittiVte.et 44 t :•531-.
<br /> V111.ComntifiDosiariment Use Only - -
<br /> rpenniqe.e.- . Datelislia issitiba.'• A.,..,•••••,. ...-, , -. ,.
<br /> Xpnroved D DitapptOseit ''S ,-
<br /> _
<br /> 1:1 CI■vrne.Given,Radon fOr Dacha. i ' • fr.3;47 • ,-dliiii°00 -1.(1.6'''' .'';‘...,,igtre ' •
<br /> . - 1
<br /> COnditions ofApproval/Reasons for Disapproval
<br /> . :
<br /> . .. . . . ...
<br /> . „
<br /> • Anaekto complete ap lartba eyerewandaaataitrs-tis..cOusty-oaly on paper listless that.8-ill:tlilricheilishe
<br /> ‘• SCANT:1\1:187-D
<br /> SBA-6398(R..08/14)
<br />
|