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DEPARTMENT OF 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 Oar: Mailing Address: <br /> ly- <br /> 30 67 C1 07 11 --�_. W_s-,S� <br /> Property L cation: r'* lage-or Township: Count <br /> Y: <br /> �% ''t:'m ?/T yd N/R �(or) W S'c c 9j cr rn 6 <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> �1 �A., L j (If assigned) <br /> 0 <br /> n C ^ �t a. C <br /> TYPE OF BUILDING <br /> ❑ Public* ❑ Variance* ❑ Number of <br /> Other (specify)* [ (4 . Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBE NEW REPLACE- OTHER <br /> RGLASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY (�J <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: v <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): ❑ New ❑ Replacement El Experimental ❑ Seepage Bed ❑ Seepage Pit <br /> �.--------"""� _ e rna i v s ecI <br /> -T e-Tp�-�--____--------•_ ----�._�..m.-.-.- �..-Q-�*w+ge..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 /> Nap3g of lumber: / L4 Si tur MP/MPR`SW No.: Phone Number: <br /> Plumber's dress: NW De� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing/g gent: Fee: Date: [ APPROVED '�Sanitary Permit:Number: <br /> / ��s �% / / '/ � � ❑ DISAPPROVED <br /> eason for Disapproval: r <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 />