1984/04/11 - SANITARY - SAN - New Non-Press - 11213

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DEPARTMENT OF APPLICATION £ SAFETY & BUILDINGS III' FOR SANITARY '" v p,, INDUSTRY, (�. i. li D,VISION LABOR AND ti%-1�1). PERMIT 1fl ' J P.O. BOX 7969 HUMAN RELATIONS '.v 1, (PLB 67) , , .•. r_� <, MADISON,WI 53707 Attach plans for the system on paper not less than 8Y2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter 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 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 included. P erty Owner Mailing Address: ro4Ct 1 e14 Ir kbl 4 .S vrn C iv, S'f 0 Pt-41111" f r bi-i v 't /4-1\-40 4 s P"/1. s'S /3•)— Property Location: 61t9,V Il,,y or Toip: Codnty: S'L t/4SLO t/4S od(AT yo N1R J'y a (or) W S' C 0 eir Ai r..-a Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: Al A; A4C t.—rio�` /1" (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 4 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY `7S- G i X k HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER 7,S'CI ) )( X, MANUFACTURER: L r 1 EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): J New ❑ Replacement ❑ Experimental 5it Seepage Bed ❑ Seepage Pit i " T 3 ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Namy of lumber: Sig MP/MPRSW No.: Phone Number: 05 v r-rc Tj C - hf h S . . J ' --+a , S, ( s )67' `6'"%/Sir Plumber's Ad�jess: Nay Designer: COUNTY/DEPARTMENT USE ONLY Si nature of Issuing Agent: Fee: Date: Q APPROVED Sanitary Permit Number: (24N- ?-1/ �.2V—'1-Ll72i' ,CJ 00 yw�0 � /—l ❑ DISAPPROVED -lJ d 1/ % 7�� ason for Disapproval: ,/ • Alternate courses)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81)