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DEPARTMENT OF - APPLICATION s SAFETY&BUILDINGS <br /> INDUSTRY, FOR SANITARY 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 BY, 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. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Property Owner: Mailing qd ress: <br /> Everet Olso.i S 1 id, 76th West Duluth, 1,2; 55.07 <br /> Property Location: 6ity,Villagaer Township: County: <br /> Gov. +i4ot l%S13 /T 40 N/R 15 .E-WW Jackson. Burnett <br /> Lot Number: Blk No.: Subdivision Nam Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> voyager Viellage Rilkare Gre n #2 (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public' ❑ Variance" ❑ Other (specify)" Bedrooms: 2 <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 750 1 X X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: TMC inc Poskiii- WT, 54,66 <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): O New ❑ Replacement ❑ Experimental 0 Seepage Bed ❑ Seepage Pit <br /> 3 3 3 420 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> & Private E] Joint 1:1Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Sig ature: q - MP/lolrlLllM <br /> Nod Phone Number: <br /> Donald Daniels 00-41 p iV (715 ) 463 2333 <br /> PlumberUrress:W Sires, WI 54172 Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Siiggnaaturee I Issuing Agent: Fee: e� Date: APPROVED S�arnitary Permit Number: <br /> G(/: vC. a_lf S-•s-�2 ❑ DISAPPROVED �(b7 SY /DO1� <br /> Reason for Disapproval: <br /> Alternate courses)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(N.03/81) <br />