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DEPARTMENT OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOPrAND - 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'/z 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: <br /> S4�=t E'f`' Lr��P� Lam/ 5z/Tlc� <br /> Property Location: City,Village or owns ip County: <br /> 6---I V '/4Ze '/aS -3 20 `71/ N/R I 'E (or W ,S°�cl ' �/..iQI►7�� <br /> Lot N`urpber: Blk No.: Subdivision Name.- _g Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> / L A) �� /�G— ( <br /> � L� =-� �� _ F1 f�14 (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> E <br /> lic* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 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 <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 Nd Seepage Bed ❑ Seepage Pit <br /> J f� ❑ 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 of Plumber: Sig ure: MP/MPRSW No.: Phone Number: <br /> Plumber's Address: Name of Designer: <br /> r 14 7 0 D /eatj 1,1 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: <br /> !- ❑ DISAPPROVED e"e0d;/ - 10V tIj J <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 />