Laserfiche WebLink
" <br /> 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 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 /> in-luded. <br /> If <br /> oN. •y Owner: Mailing Address: <br /> r` s r ne /l �, 4� t� <br /> Property Lo tion: .City,t� �or Township: County: <br /> ,3W '/4 %S O>' /TyON/R / 1@ (or) W S-' C t '7T P 1.4 r h `F l <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> /lo^ ` v ,� LD (If assigned) <br /> TYPE OF BUILDING KJ YC <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 C1 t: <br /> HOLDING r4L4K CAPACITY <br /> LIFT PUMP TANKibiv;ION CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM _ <br /> PERCOLATION RATE ASST R r /-REA �t <br /> (Minutes per inch): PROPOSED(Sluere feed: V7- Nzv L-7 Replacement ❑ Experimental 1�tSeepage Bed ❑ Seepage Pit <br /> "7 ❑� Alternative y_= pecify) ❑ Seepage Trench <br /> Water Supply: G,vner's Name as Listed on Soil Test"report (if other than present owner): <br /> gial Private ❑ Jo�t ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of <br /> ;the private sewage system shown on the attached plans. <br /> Na of Plumber: <br /> vj � � Si ure: iv_j MP/MPRSW No.: Phone Number: <br /> Nr <br /> e �.c, % kf�s �a,, , � 17/T)34t, -y/.T <br /> Plumber's Ad ress�yz <br /> f I Na of Designer: <br /> 01 <br /> COUNTY/LJEpARTMENT USE ONLY <br /> Signature of Issu' g Agent: Fee: oc Date: APPROVED Sanitary Permit Number, <br /> m / <br /> �(. G�W�"L�r✓ 0�0 /0/f! 2 ❑ DISAPPROVED 131 <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. A <br /> DISTRIBUTION: White-County,Canary-Bureau of Plurrrling,Pink-Owl-er,Goldenrod-Plumber <br /> DILHR-SBD-6398(N.03/81) <br />