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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 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 /> Prlerty caner: Mailing Address: <br /> Property Location: or Township: County: <br /> Sr_%4S ?S 1T qd N/R J�0 (or) W C. /,�-.Sv /94 0- ra e <br /> Lot umber: Blk No:: Subdivision Name: Nearest Road, Lake or andmark: State Plan I.D.Number: <br /> A. / ` (lf assigned) <br /> TYPE OF BUILDING 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 /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specif ) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: Cam.:' <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA ,+�,. <br /> (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental L Seepage Bed ❑ Seepage Pit <br /> 9 /` !/f ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: 1t Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> 1K Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> V of lumber: C Sign MP/MPRSW No.: Phone N ber: <br /> r r c JC c�i s `�- C} 3 l� /Jlu �/ <br /> Plumber's A dress: Q Na f D signer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Age t: Fee: a Date: Sanitary Permit Number: <br /> F �; APPROVED _ <br /> y�iii�G�✓ ✓ l3 7 + El DISAPPROVED y04 3U ! 0 17 <br /> .son 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 />