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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 (PLB 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8%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 /> -C.V u G--;;-/j d -2--2— <br /> (1)try <br /> Property Location: ciiy i`age•er Township: Count <br /> E% ',LJ!/,S 2L/T3gN/R /y (odW to-0-1 iNi S �/L14�v4 � vl2vt � <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> � � 1< j `5� D �' (lf assigned) ^� <br /> TYPE OF BUILDING l !� <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 orl Family *State Approval Required. 3 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY SOD Wf&I Q- 2trJ �— <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER 7 <br /> MANUFACTURER: I C—S2 ✓L o - 7'-r. H'/ 0e— Ce t1< <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per jAch): PROPOSED(Square feet): New ElReplacement ❑ Experimental page Bed ❑ Seepage Pit <br /> �/$- 11 / ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Su ply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Na of PluC2, Q / G ,� SignatMP/MPR <br /> VZV '.5- <br /> SW No.: Phone_Number: <br /> '.5-; 1 15 I S,Z,31� <br /> Plumber's Address: Name of Designer: <br /> Per— /— c, -4 7 Sl rz' 4 . 4 /SG.v AlJr ,. 17 <br /> 2-u�.� (fie✓eN .� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: i Date: gppROVED Sanitary Permit Number: <br /> 42_1" 6o� Are DISAPPROVED <br /> eason for Disapproval: iC/ <br /> Alternate counsels)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 /> D I LH RSB D-6398(R.07/61) <br />