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DEPARTMENT OF <br /> APPLICATION SAFETY & BUILDINGS <br /> • v: + FOR SANITARY ',k? DIVISION <br /> INDUSTRY, • � (� <br /> LABOR AND I , Nruu .." PERMIT I is""v ) P.O. BOX 7969 <br /> HUMAN RELATIONS ,.,•;:.y-�. � (PLB 67) � ....y4.. ,; MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 81/2 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 /> Property Owner: Mailing Address: <br /> NoKm g lnizg / 5c-70 C,LE-nil Az. Dr l4'lout,i) ; Mx S-S"36,,i <br /> Property Location: , City,Village o(Township: County: <br /> ni G 1/4N��'/4 s :a& IT qo N,R iii=fpr4w t 11 i o A/ E t!g_Ai err <br /> Lot Number: Blk No.: Subdivision Name: Nearest Roa Lake r Landmark: State Plan I.D.Number: <br /> L t L6-- yEt6,24,/ LA (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 11-41 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASSNEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY "7Sp l 2C X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: GO(r jeg CNCee '7 1) TNC"- <br /> EFFLUENT DISPOSAL SYSTEM l- <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): f,g1 New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> 3-- 3-3 �� <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> X Private ❑ Joint ❑ Public <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Signatur MP/MPRSW No.: Phone Number: <br /> AI el s eo rr�r � 2 g-y2,�t-- mp s7 c`-( 17(si Y 6-Aar'' <br /> Plumber's Address: Name pf Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: o Date: �/ APPROVED <br /> Sanitary Permit Number: <br /> `-� LZhn.LU ;`• "../`Z'�/...4;rJ L7�/ 7�- "1f ❑ DISAPPROVED y5 ;'�o l/r ' <br /> R ason for Disapproval: ,/ i <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 />