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+ APPLICATION <br /> DEPARTMENT OF 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'h 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 /> Property Location: City,Village or wnship:� County: <br /> ,560 '/a N5 t/aS 7 IT '46NIR ! E (oro & 4P77- 2-!!�/P-AAZ-_7r <br /> Lot Number: Blk No:: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> IV <br /> Z` ' �}�j�t Nb (If assigned) t <br /> y� !� 1/ tcf /-��Ei9uE �a -T� <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> .1 or 2 Family *State Approval Required. C;21 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <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: 7 mc /; S 4v/ . <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): '<New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: �tT wrier'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 /> Name of Plumber: / Sign re: MP/MPRSW No.: Phone Number: j <br /> olu,444Z) e, _ e2j4w�:_ I <br /> Plumber's Address: ` Warne of Designer: <br /> A27_ 3 go x 4-7 Q -30 ti <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing A ent: Fee: Date: APPROVED Sanitary Permit umber: <br /> ,�i/.�t( ' l` f7ir�C �U '�� 5" ❑ DISAPPROVED <br /> ason for Disapproval: /C✓ <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 />