1983/10/21 - SANITARY - SAN - New HT - 11132

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DEPARTMENT GF APPLICATION SAFETY & BUILDINGS INDUSTRY,, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,WI 53707 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 and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter 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 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 included. Property Owner: Mailing Address: Art Andren Grantsburg, WI 54840 Property Location: 97 Rirxv1kr or Township: County: SE +/4 SE1/aS 3 iT 3* N/R 18 W Wood River Burnett Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: na na na N. of 70 on County "M" (If assigned)8306632 TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. 2 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY - Ponn LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit na ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signat e: MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: Bpx W Siren , WI 54872 same COUNTY/DEPARTMENT USE ONLY S ature of Issuing Agent: Fee: Date: X APPROVED Sanitary Permit m Nuber: ,,tt !al�O c _G /U' 1"�5 El DISAPPROVED 7�� y� ��13 �) eason for Disapproval: If r<j Alternate course(s)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81)