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DEPARTMENT OF l APPLICATION <br /> r SAFETY & BUILDINGS <br /> INDUSTRY, ( �. FOR SANITARY DIVISION <br /> �'O 1 L'l 1 <br /> LABOR AND , �. 1) PERMIT Itt* <br /> "e } P.O. BOX 7969 <br /> HUMAN RELATIONS y (PLB 67) •; �,' MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 81/2 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 /> Prope t Slwn r: / /� Mailing Address: I11 { <br /> 5 MA <br /> roperty Location: City,Village or ownshi-p••� County: <br /> , i. '/4S C' t/4$�Z'9 ,T;3 ? N,R /- E (or) /off-I 14 44 uif'Ne 77 <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> // // _( assigned) <br /> i /N/ v. ACcem CFt/8 6,467j'..Z, 1�If <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> Xi 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 <br /> HOLDING TANK CAPACITYPe, /� / (� i 1 <br /> LIFT PUMP TANK/SIPHON CHAMBER `� �""� /I�� �,r �]�/'�1� 1111 pGGG"' <br /> MANUFACTURER: 0 rnUti� t/� frfr ' fI/f D/T-�V/Ir <br /> EFFLUENT DISPOSAL STEM ,Z r/, <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED/� (Square feet): El New f(Replacement ❑ Experimental [p Seepage Bed El Seepage Pit <br /> 27, ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> ❑ Private X Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na��of Plumber: Si MP/MPRSW No.: Phone Number: <br /> /["'r.4/7.�,}/PS027 �i% L k-/a?s— (7/s)6 T s e(-1 <br /> Plumber's Address: Name of Designer: <br /> 4 0 e AY 7 kie Is -C-44 6 3— 3 ,S"941 r... <br /> COUNTY/DEPARTMENT USE ONLY <br /> ture of Issuing A ent: Fee: Date: Sanitary Permit Number: <br /> r 15G / .� k APPROVED _ <br /> 1� � / ��,,� �/- 7— �S El DISAPPROVED y�665 (///>'�) <br /> eason for Disapproval: AJ7— /C✓ <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 />