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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, yet FOR SANITARY M„+ DIVISION <br /> .itLABOR AND i °° �) PERMIT Ifiv-„„,.t1oi P.O. BOX 7969 <br /> HUMAN RELATIONS r . (PLB 67) `,.•!,-.,; 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 Ad ress: <br /> Property Location: 644y,Vill or Township: County: p <br /> 1(,1:5 14 kA).1'/oS 4si iT L/ONIR /,'—a (or) W Z- ctC A"-S tl /• Air if r n p it/ <br /> Lot Number: BIk�N/o.: Subdivision Name: -Rieer-ert-ao l Lake or L-ae}m' at<r : State Plan I.D.Number: <br /> A 1'� [� •N N /v le"--( / () Gil tt. (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. a <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASSNEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACEINSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY .7 1 x x <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER 7,S"v (1 X <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): 11 New ❑ Replacement ❑ Experimental ® Seepage Bed ❑ Seepage Pit <br /> 3 4( . 2 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> K 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 PI mber: �� - Sign MP/MPRSW No.:ss Phone Number: ` <br /> Pc cr`t I j 8,7 1 1 1/ l �i ? (7/f) '66 S7 <br /> Plumber's Addr ss: �• vv Name of Des' ner: <br /> '(.A.) (2,1-tta .. 1- e/P i Jac , L <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig t eoff���Isss�suin ent/�7 yFeee: a�, Date: APPROVED <br /> ,,� Sanitary Permit Number: <br /> ;li 'J'''."` l — 6°. $ /7-7Y ❑ DISAPPROVED /5c 9Y (ii-�^?.4. ) <br /> son for Disappro al: <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 />