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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'/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 /> Prop rty Owner: <br /> V / /� Mailing Address: / <br /> roperty Location: Cite-i/i"ngL'or Township: County: <br /> t/a 'W/oS a�1 /T q0 N/R /$—B (or) W ct t ' .rh Z�cjr-." <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> / (If assigned) <br /> �✓ t r1 P �G °f <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 /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY sQ <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: C_ <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): New ❑ Replacement ❑ Experimental ('Seepage Bed ❑ Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> ;57Private ❑ 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�e: MP/MPRSW No.: Phone Number: <br /> 0 �r l L a n S. v 1 6 z�C � (��i� �66 S//J <br /> Plumber's A res Name of Desi ner: <br /> t�l L? 3 el <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign re of Issu' Agen Fee: Date: Sanitary Permit Number: <br /> o� h APPROVED <br /> 10—�o—OJ ❑ DISAPPROVED //6qY <br /> ason for Disapproval: <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 />