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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 (PL13 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8% 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 /> Aey <br /> Prok6r y Locati 'City Village o wnship• County: <br /> •%S iT N/R E (or {" <br /> L umb r. Blk o:r 9ubdivisionMarne: Neares oad, L e or Land m rk: State Plan I.D.Number: <br /> Z ' (If a n ) <br /> TYPE OF BUILDING <br /> Number of <br /> [:LPublic* ❑ Variances` ❑ Other (specify)* Bedrooms: <br /> 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER' <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specif <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 /> LJ Alternative spec) --- -- -- - ---®_Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Private ❑ Joint ❑ Public --G <br /> I, the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name o Plumber: ( Sign MP/MPRSW No.: Phone Number: <br /> W da ( E 3 <br /> PI s A dress: Name of signer: <br /> A—► I t-'► <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sig na /of Issuing ient: Fee: Ov APPROVED Date: Sanitary Permit Nu ber: <br /> � -7 <br /> r �� '0 �— ❑ DISAPPROVED ! <br /> son for Disapprova <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 />