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DEPARTMENT OF r s APPLICATION ' <br /> USTRV, .I SAFETY& BUILDINGS <br /> IND <br /> FOR SANITARY DlvlsloN <br /> LABORAND PERMIT - W P.O. BOX 7969 <br /> HUMAN RELATIONS (PLB 67) 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 data, 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. A <br /> !.< —]r— ,5` <br /> S. sem'-R.. 4 v $T / CIiIL GL. V`S <br /> 'Property Locatiom 6 �' I je orTownship: Co. <br /> 47lil %SE '/<S j6 /T j// N/R If, &(or) W v$ \" � �. <br /> Lot Number: Blk No:: <br /> Subdivision Name: Nearest Road,lake or Landmark: State Plan I.D.Number: <br /> /� A � z/. 441 (if assigned) <br /> TYPE OF BUILDING l ( !) <br /> Number of <br /> ❑ Public' ❑ Variance` ❑ Other (specify)` Bedroom:: <br /> 1 or Family "State Approval Required. <br /> TOTAL NUMBER PREFAB POUREDINNEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT ISpenfv) <br /> SEPTIC TANK CAPACITY "` _ �7 ;�?x , <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM I <br /> PERCOLATION RATE ABSORPTION AREA _ <br /> (Minutes par inch): PROPOSED(Sguare feet): ��New Replacement ❑ Experimental Q $eepage Bed E] Seepage Pit <br /> I ❑' U'�-� <br /> - -1 Seepage TrenchAlternative (specify) <br /> 1 <br /> Water Supply: Owner's Name as Listed on Soil Test Report(If other than present owner) <br /> I � Private- ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> I <br /> Name of P umber. Sig/nj�t{� /) M/P�/MPRSW No.: Phone Number: <br /> Plumber's))Add ^ N me of Designer: <br /> . �' .�f-�L�. Jr�yd'Q>� - � •C� 1�+-.tea <br /> { <br /> COUNTY/DEPARTMENT USE.ONLY <br /> I <br /> Sy azure of Issuing Agent: Fee: D to Sanitary Permit Number: <br /> / p yy e .�CAPPRORO Se <br /> /- _7.(�me ,6/(�� �� �e/s� . ❑ DISAPPROVED su A[ G .•L•Z <br /> Reason for Disapproval: Iv <br /> Alternate courselsl 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 /> OI LHR-SBD83981R.07/811 <br /> I <br />