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DEPARTMENT OF I-J 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'/2 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 /> Propertv,Owner: t Mailing Address <br /> T. <br /> Property Location: 'etp�Hr11717or Tow ship: County: <br /> S"4 ►' t/a t�l'/aS �T N/R /S_11 (or) W 1 i� f0 �f f q 7 <br /> Lot Number: Blk No.: Subdivision Name: 44earestiii7ad, Lake or Landmark: State Plan I.D. Number: <br /> A" � q (If assigned) <br /> / C W' <br /> TYPE OF BUILDING If <br /> Number of <br /> E <br /> lic* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 2 Family *State Approval Required. •2 <br /> L. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> LASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY �,j 0 / <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 I'it <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: r <br /> wner'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 /> jFe�f Pluber: (�- Signature_:g i MP/MPRSW No.: Phone Number: <br /> P r mr ,L 7� lit r1 ( t C-G � l i � c�� 1( (/7 1J )Is -YA:)%e <br /> Plumber'$Address: Na of Designer: <br /> Z, g ►�, .� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing A {n�t�y Fee: Date: p 'APPROVED Sanitary Permit Number: <br /> ��� '��? �� 1�7�c7 `� ❑ DISAPPROVED U R' Z <br /> eason for Disapproval: CJ <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 />