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DEPARTMENT OF ` APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY, FOR SANITARY DIVISION <br /> LABOR AND PERMITIV P.O. BOX 7969 <br /> HUMAN RELATIONS (PLB 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than BY: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 Address: / <br /> f( f' /1 �d (0 6 p r� 1t � 3�Urt4 � sIO <br /> Property Location: .9iey,YilFege or Township: County: �7�- <br /> 17 P Ya.SC�,1/aS ImL/T YV N/R IS F (or) W et C- �Sor. �ct.r n -P 7/ <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> e P r L Q —� (If assigned) <br /> TYPE OF BUILDING <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 INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY $'(; <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: L <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA I� <br /> (Minutes per inch): PROPOSED AREA feet): y7 New ❑ Replacement ❑ Experimental Seepage Bed EJ Seepage Pit <br /> G/3 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: 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 /> N e of lumber: Si re: MP/MPRSW No.: Phone Number: <br /> 5 7 166 <br /> Plumber's A dress: Na�f Des" er: ,� <br /> . -e. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ature of Issuirjg Agegt: Fee: � Date: APPROVED Sanitary Permi Number: <br /> // 7NJ Y�0 /b��y-�3 ❑ DISAPPROVED S�s��/G �/ S <br /> eason 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 /> DI LHR-SBD-6398(R.07/81) <br />