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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. A legible reproduction of the soil test report or the owner's copy must be <br /> included. _ <br /> Pro y Owner: Mailing Address: <br /> 7v r Sl -,- c /c / c L <br /> roperty Location: Fiay,aLitlageo ownship: County: <br /> tv vJ '/4 .S '/aS - /T L10 N/R )i7l' (or) W 4 u Jr <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> '1 + p p A!+ -,{ / ? � o /,`-f (If assigned) <br /> TYPE OF BUILDING ttOr <br /> - <br /> Number of <br /> ❑ Public' ❑ Variance' ❑ Other (specify)` Bedrooms: <br /> 1 or 2 Family 'State Approval Required. <br /> TOTALNUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 7S-C - jC. <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: 7 /A/ `, <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA _ <br /> (Minutes per inch): PROPOSED(Square feet): ❑ New ® Replacement ❑ Experimental ® Seepage Bed ❑ Seepage Pit <br /> 3 41 3 � E] Alternative (specify) El Seepage Trench <br /> Water Supply: / Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> CR Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of PI tube <br /> r: Sign MP/MPRSW No.: Phone Number: <br /> :,� 7t )C / f <br /> Plumber's Addre Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: Date: Sanitary Permit Number: <br /> r/ APPROVED <br /> 7�zCG✓ '� 7 ic[ Qat �)L�� %U- A-u� ❑ DISAPPROVED 56 57 (///s/6) <br /> eason for Disapproval: K <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£398 (R.07/81) <br />