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Wisconsin Department of Health and Social Services <br /> Plb. #67 370 Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE or USE BLACK INK <br /> A. OWNER OF PROPERTY <br /> Name Address (Street. City, Zip Code) <br /> el 71 <br /> B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY 1 <br /> Check One: <br /> CITY _ VILLAGE LEGAL DESCRIPTION <br /> TOWNSH _ �� <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO C PERMIT NUMBER <br /> D. SEPTIC TANK CAPACITY CJ Gallons NEW INSTALLATION REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place Steel Other <br /> NUMBER OF TANKS 70 BE INSTAL D=: —_ <br /> E. TYPE OF OCCUPANCY <br /> Check One: One or Two Family Residence Commercial Industrial Other <br /> Specify) <br /> Number of Persons to be Accommodated Number of Bedrooms <br /> F. APPLIANLES, ETC: Food Waste Grinder _ YES _ NO Automatic Clothes Washer _ YES— NO <br /> Dishwasher YES NO Automatic Potato Peeler YES`_ NO <br /> Other (Specify) <br /> G. MASTER PLUMBER MAKING INSTALLATION <br /> Name: (. ?�/ Address License Number: <br /> MP 1- J / <br /> Signature of Applioants // '-- .-9:. MP RSM <br /> Address: <br /> H. (To be Completed by Issuing Agent) / Q <br /> Date of Application W Qq-20 Fee Paid ; 3717 <br /> � <br /> Permit Issued (date) CS'- 9 7 61 P berms <br /> Agent (Name) I 1 u m l" �"/1• i ' For: ' <br /> !'r <br /> Ud <br /> Town, Village, City, County, etc. <br /> (Specify) <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the <br /> fee paid. Agents will forward application, the fee of $I.OU for each septic tanrc and the third copy <br /> of the permit (oanary) to the Division of Health. Checks and money orders should be made payable to <br /> the Division of Health. <br /> Do not write in space below - FOR DEPARTMENT USE ONLY <br /> I. DATE RECEIVED ACCEPTED BY RETURNED <br /> (Initials) (Date) (See Corres.) <br /> FEE RECEIVED VALID. No. PERMIT NO. <br /> es or No <br /> REVIEWED BY APPROVED DATE <br /> (Initials) Yes or No <br />