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DEPARTMENT OF APPLICATION 4042, <br /> t SAFETY& BUILDINGS <br /> INDUSTRY, t �rli FOR SANITARY i r.t1, DIVISION <br /> PERMIT rfil-1,41. 4 ILABOR AND Ill \~J0 P.O. BOX 7969 <br /> HUMAN RELATIONS r=�,� (PLB 67) , -,rr= 1� 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 /> Propert Owner: Ma• i Address: J� �^ /� <br /> Property <br /> ooky .T, 541 �J,45- . "� `l /L X79 G'L�7- -- k)/S, �T, � <br /> ///J,rtb- /�W //y7 ,T4 N/Rib -6.4er) W G+ e�rT Township: <br /> County /i'F/ <br /> Lot Number: Bik No.: Subdivision Name: Nearressttt RRoad, Lake or Landm k: State Plan I.D.Number: <br /> ,i N4- 4- si,75-//- i �� (If assigned) <br /> TYPE OF BUILDING <br /> ��//���^,�///J <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> it 1 or 2 Family *State Approval Required. . ---' <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASSNEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACEINSTALLATION MFNT (Specify) <br /> SEPTIC TANK CAPACITY .7 �\� / A/ /4}+ <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SI411.1ON C ER -�d / �j//�� � ,,�� X MANUFACTURER: GtlF/r575 v/)CRE71 /T ?mC _ / . �l�S/��ei �/�, <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA {�{ <br /> (Minutes per inch): PROPOSED (Square feet): El New Replacement ❑ Experimental AI Seepage Bed ❑ Seepage Pit <br /> P a ' Ell Alternative (specify) / ) ❑ Seepage Trench <br /> Water upply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Private ❑ Joint ❑ Public <br /> I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na rn_eof Plumber: Signature- c. MP/h4PR3tl11Vo.: Phone Number: <br /> hUr/l,1 f�F/U 0/l .586.E (761 ar6--(a, <br /> Plum is Address: Name of Designer: <br /> K4�d GU,�7_$�,�ie I Lr.H.. 5 Kc(9. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ure of Issuing Agent: Fee: a- Date: _ IV APPROVED Sanitary Permit Number: • <br /> Q�� zap � , �D i - �' El DISAPPROVED 5/:�e sy (///v0 <br /> ason for Disapproval: <br /> Alternate courses)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 />