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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'/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 wner: Mailing Address: <br /> Property Location: *,c,pillage or Township: County: <br /> r% SW%S NiR & 11 (or) W <br /> Lot Number: Blk No:: Subdivisio N me: Nearest Road, Lake or Landmark: /�— State Plan I.D. Number: <br /> N A 2 V/� C f` 'C S �. �. 46,/) (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> E <br /> lic* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> LASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY ^ '► <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): XNew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> (� Alternative (specify)_ ❑ Seepage Trench <br /> Water Supply: 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 /> N e ofPlumber- Signat e: MP/MPRSW No.: Phone Number: <br /> Plumber's Ad$^ress: Nam f esigner: rp <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuing Agent: Fee: Date: D ❑�gppROVED Sanitary Permit Number: <br /> u ld p DISAPPROVED 7 Z1 S <br /> R 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 />