1983/07/14 - SANITARY - SAN - New Non-Press - 10893

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DEPARTMENT OF APPLICATION SAFETY& BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,WI 53707 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 and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter 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 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 included. Property Owner: Mailing Address: well 4307 SAnta Fe Court Indianapolis , Ind . Property Location: SjikX\XiIDa§je}0r Township: County: NW t/4 %S 2 7 /T 41 N/R 16 F400 W Swiss Burnett Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: Minerva Rd . (If assigned) __na TYPE OF BUILDING Number of L ❑ Public* ❑ Variance* ❑ Other (specify) Bedrooms: Q 1 or 2 Family *State Approval Required. 2 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 75n 1 X X HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: TMC EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ® New ❑ Replacement ❑ Experimental ® Seepage Bed ❑ Seepage Pit 2 420 ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): ElPrivate ❑ Joint ❑ Public I same I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature: MP/y, 15t JkdX-: Phone Number: pC 'z 330 � 715 ) 463 2333 Plumbers Address: Name of Designer: Siren, WI 54872 same COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: PPROVED Sanitary Permit Number: /` / J c'T ❑ DISAPPROVED ' ason for Disapproval: Alternate course(s)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81)