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DEPARTMENT.OF APPLICATION SAFETY& BUILDINGS <br /> INDOSTRY, 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: 2� Mailing Address: <br /> q v W C 6 r .3$- S 4 i vA tvr p <br /> Property Location: Gity,Vi or Township: County: <br /> % A)F-m's /T 40 N/R 1110(or) W p oA-I. ttn v�/�C <br /> LotImber: Blk No:: Subdivision Name: Nearest Road,`La a or Landmark: State Plan I.D.Number: <br /> II+ I J`t VIS I CV i IE' ! d, � v 1P! (if assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> C�rll 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 (Specify) <br /> SEPTIC TANK CAPACITY S <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: Q C <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): ® New ❑ Replacement ❑ Experimental 29 Seepage Bed ❑ Seepage Pit <br /> 93 <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> kj Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na a of lumber: S ture: MP/MPRSW No.: Phone Number: <br /> Old, <br /> Plumber's kdd s: Na f Designer- <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Ste, Dater �y �gppROVED Sanitary Permit Number: <br /> 424_Zo J / '�l t7 �- ❑ DISAPPROVED S <br /> Ff6ason 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 /> DI LHR-SBD-6398(R.07/81) <br />