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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR AIYD 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 /> Pr erty.Owner: MailingAddre : <br /> Property Location: Gity,Villageer Township: County: <br /> SE N4 SZ t�4S a3 /T VON/R / 41 (or) W d 0 tFL. 6,it <br /> Lot Number: Blk No.: Subdivision Name: <br /> Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> Al A 71 <br /> (If assigned) gj J Y <br /> TYPE OF BUILDING J .1 <br /> Number of <br /> ❑ Public" ❑ Variance" ❑ Other (specify)` A 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 O l f1 <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 ❑ Experime ❑ Seepage Pit <br /> ternative (specify) See 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 /> N e o Plumber: Sign e: MP/MPRSW No.: Phone Number: <br /> c OeS^ y (7rs) pEF yisT <br /> Plumber I U NamR.pf Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> S <br /> i nature pJ�Vure of Issuing Agent: Fee: //11 oc Daatte: APPROVED §'anitary Pe/rmi Number- <br /> 1117&60/11 <br /> um1ber: <br /> /'.� —8,3 DISAPPROVED 7 �ti <br /> ason for Disapproval: or /<j <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 /> DILHR-SBD-6398 (R.07/81) <br />