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DEPARTMENT OF APPLICATION <br /> SAFETY & BUILDINGS <br /> INDUSTRY, FOR SANITARY <br /> 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 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 /> Property Owner: Mailing Address: <br /> S` rI~ R - <br /> Property Location: �Eity-af+HageorTownship: County: <br /> .TW '/a k' /oS iT t10N/R IS-ID(or) W "'Ta—•f .4t?C1rr1 F <br /> Lot Number: Blk NoJ: Subdivision Name: Nftawo 2—cl, Lake or_Wwvernerk: State Plan I.D. Number: <br /> y /" Cvr,.., rVyN- F�q a NQ r7� S kur� (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 19 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERG NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE LASS INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: rZi C <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): New ❑ Replacement ❑ Experimental P<Seepage Bed ❑ Seepage Pit <br /> ! p ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: D Owner's Name as Listed on Soil Test Report (if other than present owner): <br /> 7 Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N me of Plumber: Signature: MP/MPRSW No.: Phone Number: <br /> rr L <br /> 0 d �' C i r ! S G <br /> Plumber's CcIretName of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuing/A ent: Fee: Date: APPROVED Sanitary Permit Number: <br /> vr'/•rrGG� / . ii �yJ �j�• //C 6 ❑T < <br /> DISAPPROVED 3Z �OSg� <br /> eason for Disapproval: �;J <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 />