Laserfiche WebLink
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 8%: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. A legible reproduction of the soil test report or the owner's copy must be <br /> included. <br /> P erty Owner: Address: ,�/ <br /> f^ At,c0 ' )U lTep e k R%Se <br /> "Properily Location: 0*r,M or Township: County: <br /> s /a SE '/aS S /T.3? N/R /S$ (or) W //,P 4 <br /> Lot Number: Blk Nor: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.tN.mber <br /> Nor �r0 hC G { assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public" ❑ Variance* ❑ Other (specify)` Bedrooms: <br /> 1 or 2 Family "State Approval Required. e_ <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: C_ <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): F?5r New ❑ Replacement ❑ Experimental �R Seepage Bed ❑ Seepage Pit <br /> (F' 4 3 �_ ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): 71 <br /> 21 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Sig e: MP/MPRSW No.: Phone Number: <br /> Plumber's A dres : N�of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: <br /> � Oa L,^ <br /> ❑ DISAPPROVED 7r/ <br /> ason for Disapproval: C <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 /> —•• o can-6398 (R.07/81) <br />