1984/04/30 - SANITARY - SAN - Repl Non-Press - 11261

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DEPARTMENT OF APPLICATION INDUSTRY, �,V%�'1' FOR SANITARY f yi�,� , SAFETY & BUILDINGS DIVISION LABOR AND I� v, ;�1/I PERMIT i`1,r" �/! P.O. BOX 7969 HUMAN RELATIONS It , , _ . 1, (PLB 67) ,1! ' r_, MADISON,WI 53707 Attach plans for the system on paper not less than 8%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. Property Owner: Mailing Address: 7`?/L1 S% /V eA L / /Qt / 1I'V1857EAn 14/i5 , ss/8�3 Property Location: Gi-ty, 41-1 ge or Township: County: . E Y4.S E Y4S 3,S ,T 4 2 N i R /7 -E,-(eF) W Zi/I//O/V 4i A/C TT Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: f rt(If assigned) /1!p P/N5 BFFC fI S%• yt L L Ui'k�z:�1 /1/,"- TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)` Bedrooms: A1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASSNEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACEINSTALLATION MENT (Specify) SEPTIC TANK CAPACITY /200 / ;/ E-7ST/NCB 7,1AK HOLDING TANK CAPACITY LIFT PUMP TANK/a+fhf&N G4IAMBCfi '750 / X Y MANUFACTURER: w le5gie COAIrR&I f- 79 ,1 aorc �I EFFLUENT DISPOSAL SYSTEM '*' PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ElNew Z Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit G ", / /� �j' ❑ Alternative (specify) El Seepage Trench Water Supply: (� Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public /1/4- I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature MP/MRR€IAF-Abe.: Phone Number: CALAJN eE/VsolV .s_4 (7<c) gg6-{�ss Plu er's Address: Name f Designer: K f. 2 W 5 i3s%E,e I Ms-, s '9 ei 3 Cam/l.J/r'lJ -"4J 4/ COUNTY/DEPARTMENT USE ONLY Sig ture of Issuing A ent: Fee: i� Date: KAPPROVED �1 p J Sanitary Permit Number: i L � 12G f'aaD ��7 DISAPPROVED y57 '9 (//26i /) R son for Disapproval: it'J Alternate course(s)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)