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DEPARTMENT OF `_- 'APPLICATION SAFETY& BUILDINGS <br /> i INO6STRY, FOR SANITARY DIVISION <br /> LABOR AND PERMIT P.O. BOX 7969' <br /> HUMAN RELATIONS (PLB 67) MADISON,WI 53707 <br /> 1 Attach plans for the system on paper not less than 8%x 11 inches in size. Include a plot plan that is dimensioned ar drawn to scale. Horizontal <br /> Iand 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. The owners copy or a legible reproduction of the soil test report must be <br /> I included. <br /> i <br /> property Owner: Mailin0 Atltlress: <br /> �O/ 'T�22 C -�v4DF�Uf1' i14iL� <br /> Property Location: - Cib-'s'BIaR Township: County y�I <br /> 56711 S8%S 1kT3N/Ft 44IIB4-11N 0 <br /> Lot Number: 1811 1 Subdivision Name: Nearest Reed, eke r LaeCmark: State Plan LD.Number: <br /> 223,T ) LIJ60 Ae _ ufe.aiytied i <br /> TYPE OF BUI LDING - <br /> Number of <br /> ❑ Public' Cl Variance' E3 Other (specify) Betlrooms:� <br /> 1 ort Family 'State Approval Required. - <br /> TOTAL NUMBER PREFA8 POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Bpecifyl I <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY - I. <br /> LIFT PUMP TANKISIPHON CHAMBER <br /> MANUFACTURER: i <br /> / CO E P Z) StiL I <br /> EFFLUENT DISPOSALSYSTEM - I I <br /> PERCOLATION RATE ABSORPTION AREA <br /> IMinutea per tocol: PROPOSED(square feed: New ❑ Replacement ❑ Experimental �I Seepage Bed ❑ Seepage Pit <br /> 3_3 j 10 <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> I <br /> Water Supply: Owner's Name as Listed on Soil Test Report (if other than present owner): ' <br /> v Private ❑ Joint ❑ Public <br /> I <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. I <br /> Name Of Plumber Signe use: MPIMPRSW No.: PM1one Number: <br /> ✓c c klo ERPEP P S?g 17 S)5 6Cr�(6 j <br /> Plumbers Atltlress: Name of Cargoes: ... <br /> w.�z w SC. Y vets <br /> COUNTY/DEPARTMENT USE ONLY ' <br /> I Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: 1 <br /> Signature o <br /> Sou11441) SOS 7-J"P^ I El DISAPPROVED aGG�G /Da /YJ I <br /> Reason for Disapproval: <br /> Alternate Poursahl of Anion Available: <br /> 1 <br /> 7 <br /> Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (677) to be submitted to the county prior to it <br /> stallation. Failure to comply will void the sanitary Permit. - <br /> DISTRIBUTION:White-County,Canary-Bumau of Plumbing,Pink-Owner,Goldenrod-Plumber <br /> OILHR58063981N.03/81l <br />