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DEPARTMENT OF APPLICATION <br /> SAFETY& BUILDINGS <br /> INDUSTRY, FOR SANITARY <br /> 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'/z 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 /> Property Owner: Mailing Address: <br /> John Henthorne Rt. 2 Box 1125 Siren WI 54872 <br /> Property Location: for Township: County: <br /> G.L. 2 N4 %S 7 /T 38 N/R 15 &4sr) W LaFollette Burnett <br /> Lot Number: Blk No:: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> na I na na Culbertson Rd. (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> ® 1 or 2 Family *State Approval Required. 3 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> LASS <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 1000 1X X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): E3 New ❑ Replacement ❑ Experimental ® SeepageBed ❑ Seepage Pit <br /> 3 130 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: IOwner's Name as Listed on Soil Test Report Ilf other than present owner): <br /> ® Private ❑ Joint ❑ Public same <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Sign ure: _ - q MPI""49. Phone Number: <br /> Donald Daniels LeG�ACC6�J/�A ( )46 2 <br /> 393 <br /> Plumber's Address: Name of Designer: <br /> Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing Agent: Fee: 777ate: <br /> UAPPROVED Sanitary Peerrmit Number:z-0 1-1440i 7 d y El DISAPPROVED �p 7/ 9 <br /> eason for Disapproval: <br /> Alternate coursels)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 /> DILHRSBD-6398 (R.07/81) - <br />