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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 (PL1367) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8'/z 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 y Owner: % _______[Mailing Address: / / r <br /> 0" /r of 0 w p s'* G� /damn 4 h �e� C � t/ t iv �S' <br /> Property Location: Ortp-Mfflagwvr'rownship: County: ,� <br /> SWI,S f7 T N/R /� (or) W S l ciry1 <br /> Lot Number: Blk No.: Subdivisio�Ve: y Nearest Road, Lake or Landmark:. State Plan I.D.Number: <br /> Z�l (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> [EPublic* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 2 Family *State Approval Required. 3 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY f `1 <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): )Q New ❑ Replacement ❑ Experimental 0 Seepage Bed ❑ Seepage Pit <br /> cE �? 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 /> N of P tuber: Sign re: MP/MPRSW No.: Phone Number: <br /> Plumber's Addpss: _ Name of De 'gner: 1 <br /> U - iU-Sc Ste. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issuin Agen Fee: Date: 0 APPROVED Sanitary Permit Number: <br /> ' I rOD��' 7'5� V ❑ DISAPPROVED �� 7I J// <br /> 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 />