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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'/2 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 Addr ss: <br /> P operty Location: City,b'iitagC or Township: County: <br /> AjUk t/4kk-,'/aS T 37 N/R / (cE (or) W '� '`- e rI r: Yl I&U <br /> Lot Nu be r: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> / A Iy:�e , � �7� (If assigned) <br /> TYPE OF BUILDING 0`� �t <br /> Number of <br /> [EPublic* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS LASS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY / CC'Q <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 ❑ Replacement ❑ Experimental X Seepage Bed ElSeepage Pit <br /> rJ � ❑ Alternative (specify) ❑ Seepage Trench <br /> y� <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> V Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of Plumber: Sigy�aire: <br /> MP/MPRSW No.: Phone Number: <br /> 'Y �iS �EF tics. <br /> Plumber's dress: <br /> Name of Designer: R <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Iss/uu'ng A ent: Fee: r„ Date: © gppROVED Sanitary Permit Number: <br /> �1�tZfi ! ,Q- �� � � /� `J- ❑ DISAPPROVED 6 j <br /> ason for Disapproval: �f <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 />