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DEPARTMENT OF a APPLICATION 3 SAFETY & BUILDINGS <br /> INDUSTRY, ((!rR`'t ' FOR SANITARY ( DIVISION <br /> LABOR AND - ''�1�1 PERMIT Imo <br /> ; 11 P.O. BOX 7969 <br /> rY�C� I,t 1/ <br /> HUMAN RELATIONS 'r:,, ., (PLB 67) I �' <br /> „ .. ,r_.. MADISON,WI 53707 <br /> 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 <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: Mailin Address: <br /> Milton Potter 126g25 So. 100th Ave. Palos Park, IL 60464 <br /> Property Location: Rf?15619E or Township: County: <br /> GL 1 t/4 ,/4S' 26 I T 40 N,R 14 )5c/comi W Scott Burnett <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> na na na McKenzie Lake (If assigned) na <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> Q 1 or 2 Family *State Approval Required. 4 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 1200 1 x x <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: TMC Poskin WI <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): ❑ New 0 Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> 3 840 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> ® Private ❑ Joint ❑ Public same <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Signature: ( MP/ Phone Number: <br /> Donald Daniels 330 <br /> 330 ( 715)463 2333 <br /> Plumber's Address: Name of Designer: <br /> Box W Siren, WI 54872 same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing Agent: Fee: Date: r Sanitary Permit Number: <br /> t�Ct,nLO A �, li-a,,j ' �Q� �,�� ey APPROVED <br /> ason for Disapproval: c� El DISAPPROVED �x 7G,2 l// '15/ <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 />