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DEPARTMENT OF APPLICATION <br /> SAFETY& BUILDINGS <br /> `INDUSTRY, FOR SANITARY <br /> DIVISION <br /> LABOR AND PERMIT P.O. BOX 7969 <br /> HUMAN RELATIONS (PL13 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 Qwlr: y. Mailing Address: <br /> Property Locat' n: 2it�i>`iMe��r Township: County: <br /> `Z S T qON/R / &(or) W LI 07 !C P7 IF <br /> Lot Number: Blk No.: SubdivisiWarne: Nearest Road,Lake or Landma k: State Plan I.D.Number: <br /> At JvA- a (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 29 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERG 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: f <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): �C New ❑ Replacement ❑ Experimental 1�t Seepage Bed ❑ Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: F' 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 /> NP of lumber: Sig <br /> nature: MP/MPRSW No.: Phone Number: <br /> ` U G c�3 <br /> Plumber's Addt• s� s: Na f Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issuirg ent: Fee: Date: APPROVED Sanitary Permit Number: <br /> ' �� • (v /6 3 ❑ DISAPPROVED p jy 7' <br /> Offason 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 />