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DEPARTMENT OF APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY, 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'/A 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 /> Bre 1t Wernlund 900 12th St. P,aldwi:i, WI 54002 <br /> Property Location: I )IAA% 6tbr Township: County: <br /> NE SE %S 21 iT 39 N/R 19 Z44 W West Marshlatd Burnett <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> -- -- -- Bloom Road If assigned)c20 <br /> 500 <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance" El Other (specify)* Bedroom:: <br /> ® 1 or 2 Family *State Approval Required. 3 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE IN MENT (Specif l <br /> SEPTIC TANK CAPACITY 1UUU Z I X X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER $ X <br /> MANUFACTURER: nc, VOSIKI,i, <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): E3 New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit <br /> 3 3 3 P. Mound ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (if other than present ownerl: <br /> ® 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: Sign MP55iRkSIR7[a4X Phone N <br /> e: umber: <br /> Donald Daniels 330 715 ) 463-2333 <br /> Plumber's Address: Name of Designer: <br /> Sire 1, WI 54672 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: Sanitary Permit Number: <br /> // ( APPROVED p <br /> .�.��� /!!1 /r3 ❑ DISAPPROVED <br /> Reason for Disapproval: <br /> i <br /> Alternate courses)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 />�f DISTRIBUTION: White-County,Canary-Bureau of Plumbing, Pink-Owner,Goldenrod-Plumber <br /> DILHRSBD-6398(R.07/81) <br /> p_ 4� pir,c /VY ffeel1,� //��'' � _.. - . . . .. .. <br /> -2,6 <br /> _ I1 <br /> L <br /> ti. 1, the undersigned;hereby certifythat the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin <br /> Y ` and the location of the tests are correct to the best of my knowledge and belief. <br /> Admimistrative.Cotle,and that the data recorded <br /> i <br /> NAME Print <br /> TESTS WERE COMPLETED ON: <br /> ADDRESS. �ERTIFICATION NUMBER. PHONE NUMBER optional <br /> i ST SIGNATURE: L .,_ r V <br /> b, 0ISTRIBUTION:Original•LocaLAuthority,2nd page-Bureau of Plumbing,3rd page-Property Owner,4th pageSoil Tester. - <br /> �.. rG.i CRriFQnF IN n3%R11 <br />