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DEPARTMENT OF APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY-,' FOR SANITARY DIVISION <br /> LABOR AND PERMIT ��� 2( P.O. BOX 7969 <br /> HUMAN RELATIONS (PLB 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 wrier: Mailing Address: f <br /> Pro erty a n: City,Village ownship: ounty: <br /> N.S �T N�R E (or ��r �'rI�/ <br /> Lot Number: Blk No.: Subdivision Name: Nearest Ro , Lake or Land rk: State Plan I.D.Number: <br /> >t / J 0 la (if assigne <br /> TYPE OF BUILDING K/ h <br /> Number of <br /> El Public* ❑ Variance* �E_ (specify)* Bedrooms: <br /> �1 or 2 Family State Approval Require <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> 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 /> ❑ 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 /> Name lumber: Signature: _ MP/MPRSW No.: Phone Number: <br /> 9,�14 I <br /> ( S3i <br /> Plumber' dress: >-/ Name of D ig r: <br /> t�l or <br /> i� �/ ,0 //i /,logV/ <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing Agent: Fee: Date: PPROVED Sanitary Permit Number: <br /> ,O <br /> / �CJ,c% 6 LL ❑ DISAPPROVED <br /> eason for Disapproval: K� <br /> Alternate course(s)of Action Available: <br /> wl01N 2 71983 <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 /> DI LHR-SBD-6398 (R.07/81) <br />