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DEPARTMENT OF APPLICATION 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 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. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Property Owner: Mai.l�na Address: <br /> Property Location: • age or Towns ip: County: <br /> SU %/ E%S pl /TYGN/R jq* (or) W c v .©ii1`7 t <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Ian I.D. Number: <br /> M C 1 LC (f, Q (if assigned) <br /> TYPE OF BUILDING /\ <br /> Number of <br /> 1:1Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1�0 or 2 Family *State Approval Required. 3 <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): 29 New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit <br /> S— ElAlternative (specify) ❑ Seepage Trench <br /> Water Supply: `G Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> 1K 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 yyf Plumber: MP/MPRSW No.: Phone Number: <br /> ed <br /> CrIL A 'it f �o�r—�yL L9� cS`j (7rs1 Bk6 yir? <br /> Plumber' Addr ss: N 7 <br /> of esigner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: APPROVED Sanitary Permit/Number: <br /> e1 G212H ✓ �JO �0�6/L�� El APPROVED <br /> 3 ]- <br /> Reason 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 /> DILHR-SBD-6398(N.03/81) <br />