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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'h 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: �-✓1 -7-7-- <br /> u ��/` (9 C' f r /v r �r aki CjL <br /> Prope Location: may,1!F ✓•acle or Township: County: <br /> t/a -Tj-"!/aS iQ� /T 10 NiR IT (or) W j 9 C 2ie p <br /> Lot mber: Blk No.: Subdivision Name: hkecast-Reed, Lake or Ee"emerk: State Plan I.D.Number: <br /> �,;iA IV, f n0 ,T F�. (If assigned) <br /> TYPE OF BUILDING V <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. ' { <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBE NEW REPLACE- OTHER <br /> RGLASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY SO <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 FWkI Seepage Bed ❑ Seepage Pit <br /> a q ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> N Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> r0e <br /> o Plumber: ISipure:�} MP/MPRSW No.: Phone Number: <br /> Q1 tn M7 Q30S (7/5- M6`W'S <br /> Plumber's dr Nam f Designer: � <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuin Agent: Fee: Date: 0 APPROVED Sanitary Permit.Number: <br /> ✓�- 3 ❑ DISAPPROVED yD� .S//j%/0 <br /> son for Disapproval: arJ <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 />