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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 (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 /> Property Owner: Mailing Address: ,.�' <br /> r I -e r- s��`#Y �-� —13o x S(/'1/cs' c�a�iYe Y 4e.�I S S^ o <br /> Property Locationt City,Village or Township: County: <br /> '4w '/4 SW t/4S I J3 N/R /Y N (or) W S ! u Y iv C <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> LN 1 or 2 Family *State Approval Required. A <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY L <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 Pit <br /> �— �/J� ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Li than present owner): <br /> sted on Soil Test Report (If other <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: Signature: MP/MPRSW No.: Phone Number: <br /> Plumber's Address: N of Designer: <br /> / © / c-L9=� ame <br /> COUNTY/DEPARTMENT USE ONLY <br /> ature of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: <br /> , <br /> OC p? <br /> 7- -6 J ❑ DISAPPROVED 0-133 00890 <br /> eason 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 />