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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'/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 /> Pro�erty Owner: Mailing Address: <br /> Property Location: -e4y-A44ge-vrTownship: County: <br /> AjW,/oJF—'/.s 3 /T4// N/R e (or) W .S �: 1 3S 641r17 <br /> Lot Nu er: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> ,�I_ I Ki e V u �j I'���� (If assigned) <br /> TYPE OF BUILDING , "V� <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> AS <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: L <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA s� <br /> (Minutes per inch): PROPOSED(Square feet): El New t[� Replacement ❑ Experimental /Z Seepage Bed ❑ Seepage Pit <br /> 41 rf p El Alternative (specify) El Seepage Trench <br /> Water Supply: O 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 a of lumber: Sign e: MP/MPRSW No.: Phone Number: <br /> � �� T) r <br /> Plumber's A dress: Name of DesigPer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si nature of Issuin gent: Fee: Date: r� Sanitary Permit Number: <br /> /� �p / CU APPROVED <br /> J IO D fo-1 _F ❑ DISAPPROVED D�Q.� <br /> eason 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 />