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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 8% 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 /> Pro rty Owner: ,r Mailing Address: / <br /> C -r r hf f X71 o ll d �C Jac r cl r <br /> Tr <br /> Property Lo tion: tRq-b'iNege or Township: Count <br /> 'AE''/aS � /T 3 SN/R A0 @ (or) W 4A 'ert'41 t` Ar r ►7 to 7 <br /> Lot NuT er: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> �,S t fT (If assigned) <br /> TYPE OF BUILDING f t <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> (� 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGNEW REPLACE- OTHER <br /> LASS <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: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): ❑ New IX Replacement ElExperimental XSeepageBed ❑ Seepage Pit <br /> q '? ❑ Alternative (specify) El Seepage Trench <br /> Water Supply: J Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> X 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 9f Plumber: Sign MP/MPRSW No.: Phone Number: <br /> �� d<r)c F" a �th 3 -+ 030 <br /> Plumber's ddr s: Nam of Designer: <br /> , <br /> COUNTY/DEPARTMENT USE ONLY <br /> ture of Issuing Agqntyj _ Fee: Date: 'APPROVED Sia/niittaryPermit,Number: <br /> -S "' f9? ❑ DISAPPROVED r JL^�� 1JO5 <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 /> DILHR-SBD-6398 (R.07/81) <br />