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DEPARTMENT OF APPLICATION <br /> 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 /> Pr perty Owner: Mailing Address: _ <br /> Q t f -7L <br /> e 0 <br /> Property Location: feitY--b44fiag2'or Township: County: <br /> SF 1/1Nr- aS T 1Y 0 N/R /�Q (or) W G C (� /� r n,k7t <br /> Lot Nrru�,mber: 1BIkNo.:, r Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> 1 0 /� z / Af T 4k / t- (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL NEW REPLACE- OTHER <br /> FIBERGLASS <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: i <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): 5CNew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> 1 - ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: ` Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> IL Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nrof Plumbgr: Sig re: q I� MP/MPRSW No.: Phone Number: <br /> Plumber's A dress <br /> Nam of Designer: <br /> J- 91t?Y3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent Fee: Date: APPROVED Sanitary Permit N tuber: <br /> ,�uJ" o•J / pp � <br /> $�O !c ' ❑ DISAPPROVED <br /> ason 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 />