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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 8Yz 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 /> ProDtrty Owner: Mailing Address: <br /> JF <br /> /5 o K r cr S l G r S'.c � � S-S"3 <br /> Property L cation: or Township: County: <br /> '/oSLv '/aS a /T 9C N/R /yIE (or) W o 77 r-07 <br /> Lot Number: Blk No.. Subd�si Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> //IiJ /r v /G (If assigned) <br /> TYPE OF BUILDING V L <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 /> ASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 074- 1 x ?� <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): K New ❑ Replacement ❑ Experimental IWSeepage Bed ❑ Seepage Pit <br /> . q _ ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> WPrivate ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na o�um ber: L Sig re: /� MP/MPRSW No.: Phone Number: <br /> I 1 e �c /tc �( c f2 S' ''`"'Z•�• w--� C0 q I 91cT>46' /J <br /> Plumber's Amass: Name Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign at of Issuin ge Fee: � <br /> nn o Date: APPROVED Sanitary Permit umber• <br /> (9' f — ❑ DISAPPROVED <br /> R on 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 />