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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 8Yz 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 /> '11 10 LLf7C E GVFa5TE . W15 . <br /> Property Location: Qgyr-V*609 or Township: County: O <br /> '/ �JW/4S /T-rg, R lji .K or�W O J�� /ISD l�W IVE 7 <br /> Lot Num er: Blk No.: Subdivision Name: NeaTrest Road, Lake or Landmark: State Plan I.D.Number: <br /> 5l• ?[ L /Zi Af,E (if assigned) <br /> TYPE OF BUILDING JJ L s �'Y�71 <br /> Number of <br /> ❑ Public" El Variance* ❑ Other (specify)" Bedrooms: <br /> X1 or 2 Family 'State Approval Required. 'Z <br /> TOTAL NUMBER PREFAB POURED-IN 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 e, <br /> MANUFACTURER: C E <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): X New [:1 Replacement 1:1 Experimental Seepage Bed ❑ Seepage Pit <br /> i110 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: J/ 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: Signs tur MP/MPR9 r: I Phong Number: <br /> 1-10JIV 1597"&- <br /> Plum eras Address: Name of Designer: <br /> f. 2 rti F Gv15>. 3 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of <br /> Issuing Agent: Fee: � Date: APPROVED <br /> Sanitary Permit Number: <br /> GG' o�GC+L«1 Gs✓ �.3 J� �V � 7�`G� ❑ DISAPPROVED 07.2 se <br /> Reason for Disapproval: g 8,Z7 <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-8398(N.03/81) <br />