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STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR 6 HUMAN RELATIONS <br /> DIVISION OF SAFETY b BUILDINGS - BUREAU OF PLUMBING <br /> P.O. BOX 7969 - MADISON, WI, 53707 <br /> APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM <br /> Location: Township,Municipality: <br /> NE kSE k S 33 IT 140 N/R 16 MKKRXIW Oakland <br /> : <br /> Street Address: SubdivisionCounty: <br /> NA <br /> Landowners Name: Mailing Address: <br /> Herzl Camp Association Webster, WI 54893 <br /> I (We) , the undersigned, hereby make application for an alternative system on <br /> the above-described premises. 1 reaeg ise that the above premises are not <br /> If approval is granted, I <br /> agree to have the system installed in conformance with the Bureau's approval <br /> of plans and specifications. <br /> I further understand that an alternative system is more complex in nature than <br /> a conventional private sewage system and as such will require detailed <br /> inspection during construction and monituring after the system is put into <br /> use. I agree to permit both county officials charged with administering county <br /> sanitary ordinances and Bureau employes or other authorized persons to have <br /> access to the above described premises at any reasonable time for the purpose <br /> of inspection the construction of or monitoring of the system. I further agree <br /> to either personally or by my agent contact the proper county official to <br /> arrange the time and date to begin construction of the system. <br /> I understand that this application does not permit me (the applicant) or my <br /> agent (the contractor) to begin installation. If the system is approved, the <br /> Bureau will send the applicant a letter of approval which authorizes <br /> construction of the alternative system after all necessary permits have been <br /> obtained. <br /> I agree to give notice to any subsequent buyer that an application for an <br /> alternative system has been made and if installed, that the premises are served <br /> by an alternative system and further agree to give the buyer a copy of this <br /> application. <br /> The Bureau accepts this application subject to this understanding and subject <br /> to all the conditions and obligations set out in this application. <br /> Signature of Applicant Date <br /> STATE OFWISCONSIN Subscribed and sworn to before me <br /> SS. <br /> COUNTY OF ^u` This day of A/-I/ �19 d <br /> Notary Public, State of Wisconsin j <br /> DILHR-SBD-6413 (N. 05/81) My Commission Expires: <br />