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DEPARTMENT OF, <br /> ` ' APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, -' "�R`'� ' FOR SANITARY I-i Ryr1' DIVISION <br /> ,�' ,�1` `! PERMIT Itt +) P.O. BOX 7969 <br /> LABOR AND 1 � , 1/ <br /> HUMAN RELATIONS r_T „ (PLB 67) y_1^ MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8'/z 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 /> Property Owner: Mailing Address: <br /> 0nf 1 A-116Eir/ AZT 2- W :: sr WtS S' 3 <br /> Property Location: City,Village s!ownship: 1 County: <br /> S h/4 it)sE'h/'4S 3YiT'1b NiR /S'E-.(or) W fi-c iA O A/ 64//eXICT7 - <br /> Lot Number: Blk No:: Subdivision Name: Nearest Road r Landmark: State Plan I.D.Number: <br /> Cod i/ <br /> �t�T /� /� /�n - / 4 �KC (If assigned) <br /> TYPE OF BUILDING C/ <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> >V or 2 Family *State Approval Required. A <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 7Sb ( x X <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: W/eJ CE' CD eT-e D `T <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- <br /> 3 i/ [11Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> XPrivate ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for ins allation of the private sewage system shown on the attached plans. <br /> AN me of P umber: Signat MP/MPRSW No.: Phone Numb r: <br /> Jr tS pe�-per— MPS-WY (7/s 6- <br /> Plumber's Address: �. Nam f D igner: <br /> tr: 2.--- (.vt5 � we S el s 0"eIpet-- <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent:GQ Fee:` Date: Q p Sanitary Permiterit Number: <br /> �[� . cfaZiefl*) v$d D/ ��h /o 2 El DISAPPROVED / /5 ( /e.CIT Z) <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 (R.07/81) <br />