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DEPARTMENT OF � "� <br /> APPLICATM ' SAFETY&BUILDINGS <br /> INDUSTRY, FOR SANRARY AjM DIVISION <br /> LABOR AND PERMIT P.O.BOX 7969 <br /> HUMAN RELATIONS (PLB 87) go MADISON,Wl 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: Robert IdAg:ter Meiling AUra":13009 Upton Ave. S. i3ur .svilke, 11 55337 <br /> Property Location: Township: Oakla-id County. i3ur .ett <br /> SII %S14 t/aS 14 /T40 NiR16 f{aw) W <br /> Lot Nmber: Blk No.: Subdivision Name: Negre;t Road,,Lakae�oeLandmerk: State Plan I.D.Number: <br /> 7 DR L FC (if assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance' D Other (specify)* Bedrooms: <br /> 1 or 2 Family 'State Approval Required. 3 <br /> TOTALNUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 1000 X x X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANKISIPHON CHAMBER <br /> MANUFACTURER: THO i-c, Poskia WI 54!,66 <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABS PTION AREA <br /> (Minutes per inch): PROPOSED ISguare feet): E!�New ❑ Replacement Q Experimental ( Seepage Bed ❑ Seepage Pit <br /> 3 3 3 1 <br /> 0 Alternative (specify) O Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report(If other than present owner): <br /> ® Private 0 Joint Q Public <br /> 1,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nome of Plumber: Signa re: /[J5 MPNo.: Phone Number: <br /> Donald La. iels �� 1 71 ) 2333 <br /> Plumber's Address: Name of Designer: <br /> Sire.i, WI 54872 sank <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of 1 ng Agent: Fee: Data: APPROVED Sanitary Permit Number: <br /> ❑ DMAPPROVPD 5/4 ID301) <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 senitery permit. <br /> DISTRIBUTION:White-County,Canary-Bureau of Plumbing,Pink-Owner,Goldenrod-Plumber <br /> DILHRSBD-OM(N.03181) <br />