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DEPARTMENT OF APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR AND PERMIT P.O. BOX 7969 <br /> HUMAN RELATIONS (PLB 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8Y,x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal <br /> and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter <br /> H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by the designer. If designed by a Master <br /> Plumber,the date,signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Property Owner: Ile <br /> pling Address: (' t� <br /> C -fr a r IEJ C a J o � Q VW4. O 2 <br /> Property Location: %�r Township: unity: <br /> S-W % _Cl/,S I iT d N/R rO (or) W (4 /^ t r 17 'q <br /> Lot N�mber: Slk Subdiviyo� Na q r Nearestt load,�ake or I-We ark: State Plan I.D.Number: <br /> SIO tl(. Nom(_- <br /> (if assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public' <br /> El ED Other (specify)' Bedrooms <br /> IX 1 or 2 Family "State Approval Required. <br /> TOTAL NUMBER PREFAB POURED�IN STEEL FIBERGLASS NEVREPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT ISpecifyl <br /> SEPTIC TANK CAPACITY `7XO <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: G- <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minute;per inch): PRO SED .,are <br /> feet): XNew ❑ Replacement ❑ Experimental IYSeepage Bed ❑ Seepage Pit <br /> /// 'l EDAlternative (specify) ❑ Seepage Trench <br /> Water Su ply: 4' Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of lumber: Sig v MP/MPRSW No.: Phone Num er: <br /> 6 /�[e t d �/ f d 3 cY ; (7iSi �6k yr <br /> Plumber's Addre Name of Designer: <br /> V <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing�Agent: IFee: Date: APPROVED y Sanitar Permit Number- <br /> El DISAPPROVED <br /> umber:❑ DISAPPROVED o70 Arr 1//4)D17) <br /> //4)DD7 <br /> Reason for Disapproval: <br /> Alternate course(s)of Action Available: <br /> Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- <br /> stallation. Failure to comply will void the sanitary permit. <br /> DISTRIBUTION: White-County, Canary-Bureau of Plumbing,Pink-Owner,Goldenrod-Plumber <br /> DILHR-SBD-6398 (N.03/81) <br />