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DEPARTMENT OF _— APPLICATION `ivi SAFETY&BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR AND PERMIT P.O. BOX 7969 <br /> HUMAN RELATIONS (PLB 67) MADISON,WI53707 <br /> Attach plans for the system on paper not less than 8%x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal <br /> and vertical elevation reference points must R shown. All appropriate separating distances and physical characteristics as specified in chapter <br /> H-63, Wis. Adm. Code, most 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 Mai ing Address: <br /> E so L3 <br /> Property Location: Chy,Village wn <br /> o g i� / County: <br /> SE %/j97ys3 J& N/R /S-§ ) IN C ON U,0/iGT7— <br /> lot Number: Blk No] Subtlivision Name: Nearest Rpatl a!Vr Landmark: State Plan I.D.Number: <br /> ,v A14 /l n�•�N L I /i�- (If assigned) <br /> TYPE OF BUILDING lD t 'YA <br /> Ali o <br /> ❑ Public` ❑ Variance' C1ecify)Other (speearoams' <br /> L I or 2 Family 'State Approval Required. <br /> TOTAL NUMBER PREFAB POURED.(N 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: 65? - NC <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> IMinmes per incM1l: PROPOSED ISouaa feet): 'New fleplacemen[ ❑ Experimental Seepage Bed [I] Seepage Pi[ <br /> •� _ _ ❑ Alternative (specify) ❑ Seepage Trench <br /> Wamr Supply: 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 /> Name of Plumber: Sign u MP/MPRSW NN.Jo/: PM1one Numbar: <br /> Plumber's Atldress: 1/!/// Name of Designer. <br /> COUNTY/DEPARTMENT USE ONLY <br /> SiB ngre�of�I,ssuing ge Fee: 6 e Date: p RI APPROVED Sanitary Permit Number: <br /> N//r✓s/ ✓ I <br /> 50.0 Q ❑ DISAPPROVE. / <br /> Platoon for Disapproval: <br /> Alternate couplets)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-SBD63N(R.0i <br />