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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY A ALL 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 /> Property Owner: Mailing Address: _ <br /> 5F <br /> Al / •2 Y' Y rf 9So "411h N v e S o . Al l'-L C M r n/A/ �-v <br /> Property Location: - OiEy�.Lill�ga-er Township: County: <br /> )E %N,I/ %S3yiT4/0N/R /y 19(or) VV 3Ce-77 ►- Ne -7— <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> U <br /> (If assigned) <br /> i3�.i 1. rs-K <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> EV 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 ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): LZ New ❑ Replacement Elr- <br /> Experimental �X Seepage Bed ❑ Seepage Pit <br /> 3 Alb tc< ❑ 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 /> 1,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber, Signatu e: MP/MPRSW No.: Phone Number: <br /> Plumber's Address: - Name of Designer: <br /> / 3 <br /> SMT ,S `- S <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuin Agent: - Fee: n Date: <br /> ...." !Jy _ o APPROVED Sanitary Permit Number: <br /> / �J f:0 3-6 F ❑ DISAPPROVED <br /> eeson for Disapproval: 10, <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.07/81) <br />