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TRANSFER FORM <br /> PLB <br /> SANITARY PERMIT <br /> State Permit 67 - T <br /> Sanitary Permit # 40636 <br /> County 10893 <br /> Sanitary Permit Transfer Date July 22, 1983 Original Permit Issuance Date July 14, 1983 <br /> A. Property Location: NW 1/4 SE 1/4,Section 27 T 41 N,R 16 <br /> ��'�k) W Lot # City <br /> Subdivision Name, Nearest Road, Lake or Landmark BLK # Village <br /> Township 4Wicc <br /> B. TYPE of Occupancy: Commercial Industrial Other (Specify) <br /> Single Family x Duplex No. of Bedrooms Variance <br /> C. SEPTIC TANK CAPACITY _.1 - le�L() Total gallons No.of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab Concrete Poured-in-place Steel Fiberglass Other(Specify) <br /> New Installation Replacement <br /> LIFT PUMP TANK/SIPHON CHAMBER Total gallons Prefab Concrete Poured-in-place Other(Specify) <br /> D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. <br /> New Replacement Alternate(Specify) <br /> Seepage Trench: No.Lineal Ft. Width Depth Tile Depth(top) No. Trenches <br /> Seepage Bed:�Length _Width I � Depth Tile Depth(top)�No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth No.Seepage Pits <br /> Percent slope of land Distance from critical slope <br /> E.WATER SUPPLY: ® Private ❑Joint ❑Community ❑ Municipal <br /> Present Sanitary Permit Holder Phone No. � kr�4XT�: Phone No.4EiT2333 <br /> Billie Brownewell Original Plumber: <br /> Name Name Dnn Daniels <br /> Address 4307 Santa Fe Court Address Siren, WI 54872 <br /> Indianapolis, Ind. <br /> Zip Zip <br /> I,the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with <br /> section H 62.20,Wisconsin Administrative Code and that I have sized the effluent disposal system according to the EH-115 prepared <br /> by the Certified Soil T r a d/or any ad tonal soil to that may have been required. <br /> New <br /> Plumber's Signature '-� MP/MPRSW # 0 3 d <br /> Phone #- <br /> -- <br /> Plumber's Address <br /> Information obtained from (owner o agent) <br /> PLAN VIEW: Provide sketch below of any revisions to riginal sanitary permit. Include direction of slope and all distances in accord <br /> with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property or neigh- <br /> bor's ro ert . If well has of been <br /> Signature of Issuing Agent l0 <br /> 1. County (Yellow copy) 3. Owner (Pink copy) DIVISION OF HEALTH <br /> 2. State (White copy) 4. Plumber (Green copy) P.O. BOX 309, MADISON WI 53701 <br />