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/ APPLICATIONSAFETY&BUILOLt <br /> / , <br /> DEPARTMENT OF <br /> INDUSTRY,' FOR SANITARY DIVISiU�A <br /> -LABOR'AND PERMIT P.O. BOX 7969 <br /> -HUMAN RELATIONS (PLB 67) MADISON,W153707 <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 /> Pr perry Owner: Mailing Address <br /> 1. Il— �I sr D 4 � sT. sP1 . <br /> AdiN ti,- <br /> Property Location: rill, Nfdtlq --Township: County: /� <br /> $' E i SW Y.S J yl7 NIR / 76 (or) W ( /J r <br /> Lot Number: Blk No.: Start ision Name: Nearest Read,Lake or Landmark: State Plan LO.Number: <br /> 91 uh N ` solar" <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public' ❑ Variance' ❑ Other (specify)` Bdarooms: <br /> [�¢1 or 2 Family 'State Approval Required. <br /> TOTAL NUMBER PREFAB POUREDIN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT ISTHERl <br /> SEPTIC TANK CAPACITY 7D'O <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANKISIPHON CHAMBER <br /> MANUFACTURER: L' <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> More pe.inch): PROPOSED ISg dt feed: � New 71 Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> r/ <br /> 1 a C] Alternative Ispecify) El Seepage Trench <br /> Water Supply: 7 Own errs Name as Listed on Soil Test Report (If other than present owner): <br /> ()OL Private ❑ Joint ❑ Public <br /> 1,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N e of PlumberSlOnat MPIMPRSW No.: Phone Number: <br /> Plumbeis tltlress: Na eof DesiOne . <br /> L� <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si re of lip in t' Fee: Deep: O Sanitary Permit Number: <br /> O c� % / p ❑ DSAPPROV ED <br /> Z . <br /> eason for Di[approvel: <br /> Alternate coureds)of Action Available: <br /> Change of ownership, building use or plumber requires a Sanitary Permit Transfer Farm (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 SBDS398(R.07/81) <br /> .I <br />