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Wisconsin Department of Health and Social Services <br /> • <br /> Nir_lsion of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> A. OWNER OP PROPERTY <br /> Nase Address (Street, City, Zip Code) <br /> B. LOCATION OF PROPERTY WHERE SYS WILL BE CONSTRUCTED. ALT‘ap OR EXTENDED COUNTY (3 1 x 6-7 1- <br /> Check Ones <br /> CITY VILLAGE LEGAL DESCRIPTION ' '' 17 " <br /> TOWNSHIP (Block, Lot, Sec.) ` <br /> `� Cv vc�t .5'G6 1 -'-la AlIF/5w <br /> C. IS" LOCAL PERMIT REQUIRED FOR THIS WORK? ' / YES No FERMI? NJ1SER <br /> D. SEPTIC TANK CAPACITY 75-/ GALLONS NEW INSTALLATION REPLACEMENT��� ADDITION_ <br /> MATERIALSa PREFAB CONCRETE POURED IN PLACE STEEL OTHERS_ <br /> NUMBER OF TANKS TO BE INSTALLED: <br /> E. TYPE OF OCCUPANCY <br /> Cheok One: One or Two Family Residence Commercial - Industrial Other (Speoify) <br /> Number of persons to be Accommodated 1j Number of Bedrooms 3 <br /> F. APPLICANCES, ETCs Food Waste Grinder _YES NO Automatic Clother Washer ES NO <br /> Dishwasher YES NO Automatic Potato Peeler YES NO <br /> OTHER (specify) YES NO <br /> G. MASTER PLUMBER MAKING tCINSTALLATIiON <br /> Names 4 P 4 N( Ro k R 1 J E,Pi Address: Sf(Q (.'( VLZr5' <br /> SIGNATURE OF APPLICANT: <br /> License Numbers MP 3 3 3 .- <br /> ADDRESS: _g`ii'P Ill.1 _ \Ai MP RSW <br /> H. (To BE COMPLETED BY ISSUING AGENT) <br /> Date of Application Fee Paid <br /> Permit Issued (date) Permit Number <br /> Agent (nose) Fors <br /> town, village, city, oounty, etc. .(specify) <br /> NOTE, The Application cannot be considered for filing until all of the above questions are answered <br /> and the fee paid. Agents will forward application the fee of $1.00 for each septio tank and <br /> the third oopy of the permit (canary) to the Division of Health. Cheeks and money orders should' <br /> be made payable to the Division of Health. <br /> ( <br /> CCMPLETE OTHER SIDS <br />