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DEPARTMENT OF APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR.EIND - 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'/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. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Property Owner: Mailing Address: <br /> T APIC UI6 <br /> Z * o S -e 4Uf`e <br /> Property Locat�ion: /'� ct aWor Township: County: <br /> S W t/4.5{-"/4S a 7 /T ION/R lk (or') W /'4a n c/ / •r F <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Land State Plan I.D.Number: <br /> �sJ <br /> (if assigned) <br /> TYPE OF BUILDING R <br /> Number of <br /> ❑ Public" ❑ Variance" ❑ Other (specify)" Bedrooms: <br /> 1 or 2 Family 'State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE I I INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <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): ❑ New r5'.Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> (^ - ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> Q� 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 lumber: Si re: MP/MPRSW No.: Phone Number: <br /> a4k-('1e-k- 4,cok-t-113, 1 03eS;F A,E9r <br /> Plumber's A dress: IF Name�f Designer: <br /> / � <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Is y�ing Agent: Fee: Date: ROVED Sanitary Permit Number: <br /> / / // /,+✓ ; /1 - / '7 /� ❑ DIA PROVED afobel 0D/� <br /> vL it.ZWG'� a(/ Jr(i � fp —old -0 � <br /> Reason 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 (N.03/81) <br />