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Plb #67' . 7/71 A <br /> Wisconsin Department of Health and Social Servi0es <br /> 7 Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> A. OWNER OF PROPERTY <br /> Address (Street, City, Zip Code) <br /> \ -h.,"1..% /tirA';' ....-"" /1/,/e11---"t{...‘..., <br /> : ) .,244f <br /> B. LOCATION OF PROPERTY RE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENPED COUNTY <br /> Check One: <br /> CITY LLAGE LEGAL DESCRIPTION t_ L <br /> TOWNSHIP` � ti (Block, Lot, Sec.) /Vt S 4 -�i ' 2� ! YOV if /$T lye <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? tr YES No PERMIT NUMBER <br /> D. SEPTIC TANK CAPACITY Jo,'0()GALLONS NEW INSTALLATION " REPLACEMENT ADDITION <br /> MATERIALS: PREFAB CONCRETE ✓ POURED IN PLACE STEEL OTHER <br /> NUMBER OF TANKS TO BE INSTALLED: <br /> E. TYPE OF OCCUPANCY <br /> Check Ones One or NO Family Residence / Commercial Industrial Other (Speoity) <br /> Number of persons to be Accommodated Number of Bedrooms <br /> F. APPLICANCES, ETCs Food Waste Grinder _YES L. <br /> NO Automatic Clother Washer YES i <br /> uishwasher YES _LNO Automatic Potato Peeler YES _4O <br /> OTHER (specify) YES <br /> G. MASTER PLUMBER i. NG INSTALLATION <br /> Names �!� �/. i� � L� Addres s s :`/1./.,,e.4—y(--6,-A.---' <br /> SIGNATURE OF APPLICANT: 7.-Z--eA V <br /> License Number: MP y(c I <br /> ADDRESS: '')./'-.4( I-1_7d1t/ r,p RSW <br /> H. (TO BE COMPLETED BY ISSUING AGENT) <br /> Date of Application 2 <br /> ,,' `/ Fes Paid <br /> Permit Issue+ (date) V-Q �2::' Permit Number ,5f 22 3 <br /> y <br /> Agent (name) _ <br /> For: j--%,.( et'N E L.. -.4.7, <br /> town, village, city, county, etc. (a 'eoify) <br /> NOTE: The Application cannot be oonsidered for filing until All of the above questions are answered <br /> and the fee paid. Agents will forward Application, the fee of $1.00 for each septic tank and <br /> the third copy of the permit (canary) to the Division of Health. Checks and money orders should <br /> be made payable to the Division of Health. <br /> COMPLETE OTHER SIDE <br />