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DEPARTMENT-OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR ASND PERMIT P.O. BOX 7969 <br /> HUMAN RELATIONS (PL13 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. A legible reproduction of the soil test report or the owner's copy must be <br /> included. <br /> Property Owner: Mailing Address: <br /> T F/S 5TAT R iia 3 Y a <br /> Property Location: Oily,.LGiAage-or o nship: Cou <br /> 5E 1/45,=t,6S S iT N i R/ 64wr) W 5CC7-r <br /> 7771 <br /> Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: I State Plan I.D.Number: <br /> /N5 O . F (If assigned) <br /> TYPE OF BUILDING F/ife- <br /> Number of <br /> ❑ Public" ❑ Variance" ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family "State Approval Required. Z <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 Q <br /> MANUFACTURER: 7� zVzJC� y <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inchl: PROPOSED(Square feet): ❑ New Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> ..4 [ 2//Q d ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: / 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 /> Name of Plumber: Signature: MP/MPF"y#V 0.: Phone Number: <br /> t4,40N i9lsa 6�' ( 1 Ess <br /> Plum er's Address: =Name of Designer: <br /> Z WELF ,F /s• S� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: Date: Sanitary Permit Number: <br /> Q 0,> W APPROVED <br /> (L!h e! T ptilL �� �'� ❑ DISAPPROVED <br /> eason 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 /> DILHRSBD-6398(R.07181) <br />