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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'/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 /> 11 t"e <br /> Property Lo ation: QLLy_ WAW or Township: County: <br /> IV E: t/a,y�—_ %S % /T V N/R /5't (or) W <br /> Lot Number: Blk No.::V Su`bd/ijvision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> / A I� AIA j�,�a ,t, 4 r, trj v_ (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> [EPublic* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERG NEW REPLACE- OTHER <br /> LASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: C_ <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): C87 New ❑ Replacement ❑ Experimental KSeepage Bed ❑ Seepage Pit <br /> 1 (!� ❑ 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 of lumber: #� Sign re: MP/MPRSW No.: Phone Number: <br /> Plumber's Ad ress: Na of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: (�y Sanitary Permit Number: <br /> _ 14J APPROVED _ <br /> �Q 0/ J���`'���-3 ❑ DISAPPROVED yob l07 //.Z <br /> Rffason for Disapproval: �J <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 />