1983/10/24 - SANITARY - SAN - Repl HT - 11135

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DEPARTMENT OF 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'Y2 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: Al Blume Yellow River Inn Webster , WI 54893 Property Location: Xi34x%XD{ai*Xr Township: County: SE y4 NE+�4S 5 /T 39NN/R 16 g,� W Meenon Burnett Lot Number: Blk No:: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: na I na na Highway 35 N of Webster (if assigned)8 3 0 6 6 3 3 TYPE OF BUILDING Number of Ej Public* ❑ Variance* ❑ Other (specify)* Bedrooms: ❑ 1 or 2 Family *State Approval Required. na TOTAL NUMBER PREFAB POURED-IN STEEL NEW REPLACE- OTHER FIBERGLASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: TMC inC. Pos kin WI EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED(Square feet): ❑ New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit na na ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): ER Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature:: MP/�/ 5tsA%,No.: Phone Number: Donald Daniels ,r��`� � 330 1715 )463 2333 Plumber's Address: Name of Designer: Box W Siren, WI 54872 same COUNTY/DEPARTMENT USE ONLY Si ature of Issuing Agent: Fee: Date: W APPROVED // 19550�' Sanitary Permit Number: l /0' Y-f3 ❑ DISAPPROVED 71�6 J D ( .111.33-I eason for Disapproval: 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- ;tallation. Failure to comply will void the sanitary permit. ASTRIBUTION: White-County,Canary-Bureau of Plumbing, Pink-Owner,Goldenrod-Plumber )ILHR-SBD-6398(R.07/81)