Laserfiche WebLink
DEPARTMENT OF ' ' APPLICATION 1` � - 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 6h 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 /> Property Owner: - Mailing Atldress. j_V 1 <br /> "T- <br /> _ n <br /> -2rC{gh-rto l.Jv 7W f.1L- (_/L <br /> Property Location: �GSy-itiNege-emTownsM1ip: County: <br /> S Lt/< 5lv'%s 33 ,T 3 N/R /6 (or) W <br /> Lot Number: Blk No:: Subtlivision Name: I Nearest Road,Lake or Lantlmark: State Plan I.D.Nu <br /> v / fir-, %Z (1 � <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance' ❑ Other (specify)* eedmoms: <br /> ��r 2 Family State Approval Required. 2/ <br /> TOTAL NUMBER PREFAB POUREDIN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MT <br /> (SFanfVI <br /> SEPTIC TANK CAPACITY 7 y.� / Y<� /O NO p ✓ems pl0 <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER ' <br /> MANUFACTURER: W 1, - a7 '.- //' ... _e__ �_%� 4� c <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> IMinutes Far inch): PROPOSED(Square Iced: 02'New ❑ Replacement ❑ Experimental L'� Seepage Bed ❑ Seepage Pit <br /> 4 x ❑ Alternative (specify) El Seepage Trench <br /> Water Supply: Owner's Name as Lined on Soil Test Report (If other than present owner): 1 <br /> ivate ED Joint ❑ Public ��s" ' <br /> 1,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> of Plumber: (� Signature: L! Z MP/MYPRSW No-: Phpne Number: <br /> -T.'✓- 2 /J9 o:�✓6 dam/ / (/ ✓� 5'_ 2:/ (7if16.Y5,z3/ <br /> Plumber's Atldress: Name of Designer: <br /> �e / 5/3 Ste / G//fcoa.., . - / .. 6t/ ✓vim i <br /> COUNTY/DEPARTMENT USE ONLY <br /> S netura of Issuing Agent Fee:` Date: yy �AppROV ED Sa>nitary Permit Number. \1 <br /> t2 ❑ DISAPPROVED 3D6�3� <br /> Reason forDisapproval: <br /> Alternate coursehl 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. 1 <br /> DISTRIBUTION:White-County,Canary-Bureau of Plumbing,Pink-Owner,Goldenrod Plumber 1 <br /> 01 LHRSB13S398(R.07)81) . <br />