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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 8Yz 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 /> Prols.ty Owner: Mailing Address: <br /> h �1Z '50 1 ASi CS ��2 <br /> Property Location: City,Village Township. County: <br /> 'S6 %S 15%S /TbN/RI W ¢C v1—/I�p <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, ak or Landmark: State Plan I.D. Number: <br /> Irc Q/ + Ke If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public" ❑ Variance* ❑ Other (specify)" Bedrooms: <br /> 1 or 2 Family 'State Approval Required. vZ <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT I(Specify) <br /> SEPTIC TANK CAPACITY $'D <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: woes Co"CY At C_ <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): I PROPOSED (Square feed: Q� New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> q1_ q_ t4 3 a El Alternative (specify) L] Seepage Trench <br /> Water <br /> 'Slupply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> tK Private ❑ Joint L2Public <br /> I, the undersigned,hereby assume responsibility for nstallation of the private sewage system shown on the attached plans. <br /> Name of Plumber- Sig u MP/MPRSW No.: Phone Number: <br /> WS-7.0`r (7t- <br /> Plumber's Address: Name of Des" ner: <br /> Rt Z 1.�1e�S �- UJLS PN r <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ture of Issuing Agent: Feed ov Date: �7 G_ APPROVED Sanitary Permit Number: <br /> /" �O s� a —J �O 5 ❑ DISAPPROVED 11F f3 <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 /> DILHRSBD6398(R.07/81) <br />