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• <br /> DEPARTMENT OF a - APPLICATION <br /> SAFETY& BUILDINGS <br /> INDUSTRY, , t tVi FOR SANITARY Yaar k. k1 ! ( i r ., I DIVISION <br /> LABOR AND i11,!4C� PERMIT I v"' P.O. BOX 7969 <br /> HUMAN RELATIONS ! r . (PLB 67) f-,4 MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8'/2 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 /> Propertyh Owner: Mailing Address: <br /> ene 1.40chy4 Ic�13 0% � 6 - 4� e esr t Pc 4 h <br /> Property Location: -.0 y-�4�4ago-or Township: County:: <br /> SE 1/a jE'/aS .) ? IT y(? NiR / ,S'®(or) W -4 G c /5 c � ,674, r r7 <br /> P 7/— <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> ((J A kcii— (Pe r 4 . J 0 - (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 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 7,S- 0 / x >< <br /> HOLDING TANK CAPACITY /� <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: 'i C <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> 3 q t3 . — Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> E Private ❑ Joint ❑ 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 e: /� MP/MPRSW No.: Phone Number: <br /> �—A.. i,✓` (s 0 5 ( f ► <br /> Plumber's Ad ess: 1 Name^f Desig r: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing A ent: Fee: Date: Sanitary Permit Number: <br /> L 0 APPROVED <br /> 7�2Eo - /t�C�'sZ7L/ , t> > 5'7/4 ❑ DISAPPROVED �.SSw /D(o SC) <br /> ri7 ason for Disapproval: / <br /> Alternate coursels)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 />