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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 (PL13 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 /> Property Owner: Mailing Address: <br /> F {'- QSoN <br /> Property Location: or Township: County: <br /> IVE %NG(/'/aS /T NSR Eger) W -4 L 04� XFT <br /> Lot Number: BlAk,No.: Subdivision Name: Nearest Road,Lake or Landmark- s State Plan I.D.Number: <br /> 'v /i 5? �O <br /> (if assigned) �M <br /> TYPE OF BUILDING �V /- <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. Z <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: 5' �� Gv/S• <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): ❑ New Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> y ///o p/ ❑ 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 /> Name of Plumber: Signa tu MP/MM19WINo.: Phone Number: <br /> LUN s (yis) 86G-5�6s <br /> Plu er's Address: Name of Designer: <br /> Rj <br /> Z Lc> T <br /> COUNTY/DEPARTMENT USE ONLY <br /> nature of Issuing A ant: Fee: Date: Sanitary Permit Number: <br /> c,, 10 APPROVED / <br /> a%iu-i'� dU ����.J ID 10 <br /> e6 4.5-- 77Q J_ <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 />