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Plb #67' 7/71 - . <br /> Wisconsin Department of Health and Social Services <br /> Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> A. OWNER OF PROPERTY <br /> Address (Street, City, Zip Code) <br /> B. LOCATION OF PROPERTY WHERE SYST WILL BE CONSTRUCTEDALTER <br /> EXTENDED COUNTY '` t! <br /> Check Onet <br /> CITY j VILLAGE LEGAL DESCRIPTION <br /> TOWNSHIP (Block, Lot, Seo.) ZPbAVZJ <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES J No PERMIT N"XR <br /> D. SEPTIC TANK CAPACITY U GALLONS NEW INSTALLATION v REPLACEMENTS ADDITION <br /> MATERIALSt PREFAB CONCRETE 4-� POURED IN PLACE_ STEEL OTHER <br /> NUMBER OF TANKS TO BE INSTALLED: <br /> E. TYPE OF OCCUPANCY r <br /> Check Ones One or Two Family Residence-7/CommercialIndustrial__ Other—(Specify) <br /> Number of persons to be Accommodated 3 Number of Bedrooms,- <br /> F. APPLICANCES, ETC: Food Waste Grinder YES (NO Automatic Clother Washer YES Z—NO <br /> Dishwasher YES NO Automatic Potato Peeler YES _NO <br /> OTHER (specify) YES NO <br /> G. MASTER PLUMBER t INSTALLATION <br /> 1• _ l /L <br /> Name: y .. Addresst <br /> r <br /> SIGNATURE OF APPLICANT: <br /> License Number: rip 7 '✓ / <br /> ADDRESSs d .-f 7;v_�� :G .. MP RSW <br /> H. (TO BE COMPLETED BY ISSUING AGENT) <br /> Date of Application Fee Paid <br /> Permit Issued (date) Permit Number <br /> Agent (aegis) Pars <br /> town, village, city, county, oto, specify) <br /> NOTEt The Application cannot be considered for filing until all of the above questions are answered <br /> and the foo paid. Agents will forward application, the fee of $1.00 for each septic tank and <br /> the third copy of the permit (canary) to the Division of Health. Cheeks and money orders should <br /> be made payable to the Division of Health. <br /> COMPLETE OTHER SIDE <br />