Laserfiche WebLink
DEPARTMENT OF 3 APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR AND PERMIT P.O. BOX 7969 <br /> HUMAN RELATIONS (PLB 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8% 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: --JMailing Address: <br /> SlAfc' /.Z-f &,Ise <br /> Propert Location: City,Village or ownship: County: <br /> '/4S �iT `� N/R / E (or > <br /> Lot umber: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> x n � L ��� �\ (If assigned) <br /> TYPE OF BUILDING J <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB IN STEEL NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE L FIBERGLASS INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY `G , 4-- <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): ❑ New XReplacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> 4�)n ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: 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 /> N e a lumb Signature: MP/MPRSW No.: Phone Number: <br /> �a T- �� - j'�iQcaj�yz 7 3 cal 2 <br /> Plumber's Addre s: Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sj ature of Issuin i Agent: Fee: Date: _ [ APPROVED Sanitary Permit Number: <br /> GZd7 rtir/NAG r L� _ ❑ DISAPPROVED ���� <br /> eason for Disapproval: <br /> 07 <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 (R.07/81) <br />