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APPLICATION <br /> DEPARTMENT OF, , , SAFETY& BUILDINGS <br /> •INDUSTRY, ((, R � FOR SANITARY f- . �i DIVISION <br /> LABOR AND Ir�irtJ`��) PERMIT ;f t 1) P.O. BOX 7969 <br /> HUMAN RELATIONS f r (PLB 67) 1 y 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 /> (.9 ez)L6 -E. 30 /-lAsmi .2T 1 Z 0 X ) PA-/3viZ y . £'iS SY 0 <br /> Property Location:1 eitq-V4(e oiownship- County: <br /> �'e' v4 t yl1/4s `i iT 410 O NJ/R )( -b,4) w 0 1 K 8 t012 it Orr <br /> Lot Number: Blk No.: Subdivision Name: Barest RooP Lake or Landmark: State Plan I.D.Number: <br /> till Y DC".7!) Z.Aec f (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 :'-JS 0 i X x' <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBERr <br /> MANUFACTURER: IA)1 1 S r CoNCleC rC pi4i D. <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): a New cXI Replacement ❑ Experimental E Seepage Bed E Seepage Pit <br /> ��C ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> X Private ❑ Joint ❑ Public-- S,9 i1 Cam` <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber: Signat re:„ . MP/MPRSW No.: Phone Number: <br /> ik)a C. I O pf. /iJ_ k`-2-114---"'" PIP S7,9 s< (7/T) e, 3" <br /> Plumber's Address: Name of Designer: <br /> • <br /> t't,LP 1,7 S t-fv LJr s 5 c- — <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: Sanitary Permit Number: <br /> ' � APPROVED <br /> /� � 9t^�t,vL) Jj�(� S"a'e7 2 ❑ DISAPPROVED a 4796 6d032) <br /> Reason for Disapproval: <br /> Alternate course(s)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 />