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DEPARTMENT OF APPLICATION <br /> SAFETY & BUILDINGS <br /> INDUSTRY;' ^ FOR-SANITARY DIVISION <br /> L ABOR'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%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 /> PrZrty Ow r: Mailing <br /> Address: <br /> '4 Y' � 0 " S C _� t / '_ Y" L- - i .S C <br /> Property Location: C44y,Vi}}a.9e or Township: County: <br /> S"F_ %S�'/4S 3 /T 3 N/R / (or) W A,,'j rt' t -% C .-\� ,9(',, -­ " H `/ <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> (if assigned) ;?j' (t <br /> TYPE OF BUILDING J <br /> Number of <br /> E <br /> lic" ElVariance* ❑ Other (specify)* Bedrooms: <br /> 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> J;kALLONS 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): uare eet : ew ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit <br /> �'— ❑ Alternative (specify) �'� Se{aage`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 /> N;7 of P}umber: Sign MP/MPRSW No.: Phone Number: <br /> Plumber's j dre • Name f Des ner: <br /> COUNTY/DEPARTMENT USE ONLY <br /> ;eason <br /> nature of Issuing Agent: Fee: e� Dapte: f� PPROVED Sanitary Permit Number: <br /> - '��" a 17i�6 ❑ DISAPPROVED 7' o2rg <br /> 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 />