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DEPARTMENT OF p^ <br /> erEst APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY, 6: �`y�,�i j FOR SANITARY i",:,}IK1 � DIVISION <br /> LABOR AND i i�v, ) PERMIT i i ;�� j P.O. BOX 7969 <br /> HUMAN RELATIONS �,'r� (PLB 67) ,� .'••? ��• 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. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Property Owner: Mailing Address: <br /> at Mkt ev v1 6Qr dry *r ,a 4 Ai iti. 45c „ Al. v a( <br /> Property Ldcation: 6 W4�' �'' or Township: Coyly: <br /> '/4 AYRIAS .S e)iT /� N/R iy 0(or) W ,t''/r /i Cr 1—/2 4,e in- <br /> Lot Lot Number: Blk No.: Subdivision Name: Ne st Road, Lake or Landmark: State Plan I.D.Number: <br /> 01-0 // (lf assigned) f <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> t* 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 iQttl _ / ,C ›, <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: (,v C /e) <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Mi tes per inch): PROPOSED(Square feet): New ❑ Replacement ❑ Experimental 5eSeepage Bed ❑ Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> K Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> de f Plumber: Sigrt2tgre: i j MP/MPRSW No.: Ph ne Number: <br /> NPC- if 147'n. s (/�)/ �P w d ,.6S'5j ( 6 ) q/J"' —7iS <br /> Plumber's ddress 1 Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: Sanitary Permit Number: <br /> `e �a�d'� ® APPROVED 074462 /0,]Ol11 <br /> < <br /> /. -CA- --4-G%1' SD CI DISAPPROVED <br /> Reason 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 (N.03/81) <br />