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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 Address: <br /> Property Lo ation: 6ai+},AL'" ^^�r Township: Cou y:\y;% W'/aS /T y O NiR J y E (or) W S'Co 7t .62 Q r h Lo <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> (If assigned) <br /> TYPE OF BUILDING <br /> Nmber of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Beudrooms: <br /> 1 or 2 Family *State Approval Required. .1-- <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY S`V <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): Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> 3 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: ___jOwner'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 me of Plumber: Sign ture: MP/MPRSW No.: TPhone Number: <br /> c 4`P PfC (7i3)fU- ill <br /> Plumber's ddr Nam of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: Date: Sanitar Permit umber: <br /> a APPROVED y _ <br /> 1;5 ❑ DISAPPROVED <br /> eason for Disapproval: /t'.J <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 />