Laserfiche WebLink
t <br /> DEPARTMENTF APPLICATION ,O SAFETY& BUILDINGS <br /> INDUSTRY, t ` 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'/z 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 /> / L , lerlo nX 93.2 A' ,crE 4FM4166: A441 /2 <br /> Property Location: 194,,Village or Township: ty: <br /> 5Iµ1 '/4 W '/4S /TS/Q N/R /d/ W SeO7"r A3WX/9/oC_77' <br /> Lot Number: Blk No:: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> NAAIR ?Lin j �t 7.0 615 K._ "'assigned)Ntf <br /> TYPE OF BUILDING <br /> Ll <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> Al 1 or 2 Family *State Approval Required. 2 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> AS <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY / <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/81PI08114 WAMe R G <br /> MANUFACTURER: /E$ Z014 P459JA1 <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA rM M <br /> (Minutes per inch): PROPOSED AREA feet): kL New ❑ Replacement 171X <br /> Experimental Seepage Bed ❑ Seepage Pit <br /> L 3 L7//� ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Z Private ❑ Joint ❑ Public /(fQ <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Signatu - MP/MPFl9Yl�No.: Phone Number: <br /> VIA/ 0ENSON <br /> Plumber's Address: Name of Designer: <br /> W65 566je W15. 5Y 99-T SF,4150,41 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing A ent: Fee: Date: Sanitary Permit Number:. " <br /> APPROVED �— <br /> ClrrFlJ ❑ DISAPPROVED <br /> Rufison 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 sanitary permit. <br /> DISTRIBUTION: White-County,Canary-Bureau of Plumbing, Pink-Owner,Goldenrod-Plumber <br /> DILHR-SBD-6398(R.07/81) <br />