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,.,. APPLICATION <br /> DEPARTMENT OF t SAFETY & BUILDINGS <br /> INDUSTRY; 61114'1 r FOR SANITARY miff), <br /> / �, �1 I• �� y, �1 ) DIVISION <br /> LABOR AND 1 ' =,'1 PERMIT lir <br /> io . ` P.O. BOX 7969 <br /> j! r�J/i J I <br /> HUMAN RELATIONS . -r. ,. <br /> (PLB 67) I :;:,,y_,, ' MADISON,WI 53707 <br /> 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 <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 /> Ccz`-1 61 Eor?ee1 RI- I D4/764•Ji i (CISc, S'`(3'3U <br /> Property Location: City,Village ownshig? County: <br /> S %c) IA '/4S I? /T go N,R is- = Go .ja c id'oit/ : vrn et* <br /> Lot Number: Blk No.: Subdivision Name: Nearer oad)Lake or Landmark: State Plan I.D. Number: <br /> / O-41.+ R Dq r tt it (If assigned) <br /> TYPE OF BUILDING l r`l C' <br /> Number of <br /> El Public* ❑ Variance* ❑ Other (specify)* 1i7 bi f M'!1>_ Bedrooms: <br /> y 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASSNEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACEINSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 7 3D / X <br /> X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: ( t.)1 f5 efr- e--C7n C r $e 'P y.a'd ' . <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): X New ❑ Replacement ❑ Experimental tA.1 Seepage Bed ❑ Seepage Pit <br /> 3 q ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> IX Private ❑ Joint ❑ Public <br /> I, the undersigned, hereby assume responsibility for in allation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Signat re: MP/MPRSW No.: Phone Number: <br /> �!e lS o -92F ' - - -L - nip 18`{ (7(5-) H•- " <br /> Plumber's�Address: .�n L A Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: <br /> /' e - /J -/ (, <br /> UiyrLe.� ���(�'' ��`//-C J El DISAPPROVED yS6/� (I/a?/5 <br /> ason for Disapproval: ICI <br /> Alternate coursels)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 />