1984/05/07 - SANITARY - SAN - New Non-Press - 11282

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DEPARTMENT OF - , i 7 APPLICATION SAFETY & BUILDINGS INDUSTRY, t,, ' FOR SANITARY 7✓;M r DIVISION LABOR AND 11°4041 � PERMIT . `r 3 i ) P.O. BOX 7969 HUMAN RELATIONS ,rT, ,, (PLB 67) , ' ,r_A-1.; MADISON,WI 53707 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 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: Jim N. Childs 13012 Shady Dale Rd. MInnetonka, MN 55342 Property Location: ownshi County: p: Coun y: GL 1 '/4 'AS 24 ,T 40 N,R 15 E-(414) W Jackson Burnett Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: na na na Cty "A" & Dhein Rd. (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)" Bedrooms: ® 1 or 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW I REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 1000 1 X X HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: zmr in Poskjr, WT EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): © New ❑ Replacement ❑ Experimental ® Seepage Bed ❑ Seepage Pit 3 630 ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): © Private ❑ Joint ❑ Public same I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signal a —"_ d MP Phone Number: Donald Daniels 330 (715 )463 2333 Plumber's Address: Name of Designer: Box W Siren, WI 54872 same COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: ,, Date: gppROVED Sanitary Permit Number: ./� a (/ e?i1121+,� „L�'a'Sc vlJ r✓ :/�'t el.- ;- - 7.-1�y DISAPPROVED 5,.2 ]C'U /-2 ('� Ridason for Disapproval: Alternate courses)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 IR.07/81)