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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABDR`AND _ PERMIT P.O. BOX 7969 <br /> HUMAN RELATIONS (PL13 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 /> Pr erty Owner: Mail' g Address: <br /> h -r In �S� , 4 s�GiJ 0 <br /> Prop° Location: Ly, or Township: County: <br /> t/aS %4S )q /T qp N/R IS B (or) W ct c G - ,-• 46� r_101 tom' <br /> Lot Number: Blk No:• Subdivision Name: • Nearest Road, Lake or Land ark: State Plan I.D. Number: <br /> �" (if assigned) <br /> i`f �� it <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS 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: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): � New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> 7 q 2 '�L_ ❑ 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,Plumber: Sign e: MP/MPRSW No.: Phone Number: <br /> c r i. �!di s - Y c� F 9 s,►F6 6-Ws <br /> Plumber's Address: Name fner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si 74ture of Issuing gent: Fee: C Date: l PPROVED Sanitary Permit N ber: <br /> '�4 � // �3 ❑ DISAPPROVED /OZ <br /> ason for Disapproval: ICU <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 />