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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 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 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 /> included. <br /> Property Owner: -. Mailing Address: <br /> Chris Bilotta 21,13 Maple View; 'Maplewood, Miq 55109 <br /> Property Location: rTownsh Township: County: <br /> % %S 12 /T 37 N/R 1< BXa4 W Trade Lake B:.traett <br /> Lot Numbar: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> Gov, lotl ---- ----- Spirit Lake (If assigned) 2,20190u <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. 2 <br /> TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY 'M10 I <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: n <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet):FEDIAlternative <br /> New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit <br /> ------ (specify) <br /> ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Gi 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: DO!721d Daaels Signatu4� �/- MPlICI@F}91gg1tp.: Phone Number: <br /> 45,� 330 1 ( 7151463 2333 <br /> Plumber's Address: Box Yl Sire ;., WI 54672 Name of Designer: <br /> same <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Luing Agent: FeG Date: APPROVED Sanitary Permit Number: <br /> Reason for Disapproval: <br /> d{ —IIS r� ❑ DISAPPROVED �lo S`�o2 IO/.Z J <br /> Alternate counsels)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-SBD6398(N.03/81) <br />