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DEPARTMENT OF <�" %�� , APPLICATION
<br /> SAFETY& BUILDINGS
<br /> INDUSTRY, ,... r' FOR SANITARY (t M,,* DIVISION
<br /> j PERMIT ;
<br /> •ic j Jti ioi i``
<br /> LABOR AND Ilt. + C P.O. BOX 7969
<br /> HUMAN RELATIONS _ ., (PLB 67) ,:, ;,:yN. /,; MADISON,WI 53707
<br /> •Attach plans for the system on paper not less than 81/2 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 wner: Mailing Address:
<br /> a.r, fl; Z. .4 zso.a\, / e_r, 1 Sc- 02(4 4i o 6/ a_z .,4.. 6- f il-
<br /> Property Location: r Township: County:
<br /> 1/4 sS '/4S 7ITe_537NIR /A'.E1330W &Jovd2 Th cir47. ,o' -4,--/-7 E7/
<br /> Lot Number: Blk No.: Subdivision Name: Nearest Road,�r Landmark: State Plan I.D. Number:
<br /> �! 9 i.,
<br /> (;[ le
<br /> 3 eras Cr!S L 4k 2 ,�OYc`- XU. Le d0G I.,�� (If assigned)
<br /> TYPE OF BUILDING
<br /> Number of
<br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
<br /> EI—For 2 Family *State Approval Required.
<br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASSNEW REPLACE- OTHER
<br /> GALLONS OF TANKS CONCRETE PLACEINSTALLATION MENT (Specify)
<br /> SEPTIC TANK CAPACITY
<br /> HOLDING TANK CAPACITY s•t, . :_.----- i,,,-----
<br /> LIFT PUMP TANK/SIPHON CHAMBER
<br /> MANUFACTURER:
<br /> EFFLUENT DISPOSAL SYSTEM
<br /> PERCOLATION RATE ABSORPTION AREA
<br /> (Minutes per inch): PROPOSED (Square feet): ❑ New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit
<br /> ❑ Alternative (specify) ❑ Seepage Trench
<br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
<br /> vate ❑ Joint ❑ Public
<br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
<br /> NNa,mee of Plumber: �_, Signature: .,�� MP/MPPRSW No.: Phone Number:
<br /> �j
<br /> t''g(f :--c? /L"f,v, v,,,....7 (.___-7(.___-757'Z/ (7�3-)61-5=6 3/7
<br /> Plumber's Address: Name of Designer:
<br /> 4---/— ,6 k- -; 77 Sim r;.., !v,'-S e U4.5.,.... 5,
<br /> COUNTY/DEPARTMENT USE ONLY
<br /> S- ture of Issuing A ent: Fee: Date: Sanitary Permit Nymber:_ E APPROVED
<br /> /. > , '1, -n- CJ (p `7 A �}��� El DISAPPROVED %" -5� (PP / p
<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 /> DILHR-SBD-6398 (R.07/81)
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