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APPLICATION <br /> DEPARTMENT Or SAFETY& BUILDINGS <br /> INDUSTRY, FOR SANITARY AA& 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. A legible reproduction of the soil test report or the owner's copy must be <br /> included. <br /> PropertYOwn Mallin A <br /> Property Location: <br /> D � LSQIV /[. Z <br /> a/tion: Cil4i4Be�a or Township: County: <br /> I Et14 A51/4S T 55r N/R 16P&4er) W <br /> Lot Number: Bilk No.: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D. Number: <br /> /Ii A/q AwM41,,-* // (If assig <br /> TYPE OF BUILDING <br /> / 77 h/rT <br /> Number of <br /> Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <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': <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I 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 /> ir 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: r MP/Mf'RBMIFNo.: Ph ne Number: <br /> elfwlN .C3 so/Y 6S (lis <br /> Plum is Address: Name of Designer: <br /> • 2 /3�UsQA1 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: p APPROVED Sanitary Permi Number: <br /> O "D % 11 ❑ DISAPPROVED <br /> eason for Disapproval: KJ <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 /> DI LH R-SBD-6398(R.07/81) <br />