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DEPARTMENT OF ' APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY, (-..�`r y"�.�1'i FOR SANITARY /-t. r 1114\ DIVISION <br /> LABOR AND • <br /> I C'11) PERMIT ;r1 fv� : t1 P.O. BOX 7969 <br /> HUMAN RELATIONS ! r (PLB 67) 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. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Property caner: Mailing Address: <br /> Ai t 1..rs• id 4 7 fi <br /> c, il L 4 t‘4 Rd AcrkfsiN mi 01 <br /> Property Location: i age or 6wnship: C unty: <br /> ►skl; Y4 7VF S �.7iT q '3 NiR /5-E (or) W ct c 3'0 rs aid e, rr* 771-- <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> / 7 ej c.a (''�' /�/ <br /> I I*.,F,S � (lf assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> t1 1 or 2 Family *State Approval Required. -.? <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY /10 el x x <br /> HOLDING TANK CAPACITY <br /> • <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: ( U t <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): New CI Replacement ❑ Experimental `Seepage Bed El Seepage Pit <br /> ri 4 if a, ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> 54 Private ❑ Joint El Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of lumber: Si re: MP/MPRSW No.: Phone Number: <br /> 9 <br /> Ra ` ^IC4- ks 6 as? (jar ai, Y,d1 <br /> Plumber's Addr Name of Designer: <br /> 54 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: o a Date: Sanitary Permit Number: <br /> // yr� �a APPROVED 0037e.) <br /> (�/• d`�• �� ---- 9-/3-12 ❑ DISAPPROVED 3�Y)Y <br /> Reason for Disapproval: <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 (N.03/81) <br />