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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 (PLI3 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. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Pro erty)Owner: M{a?iliTng Address: <br /> ,Q,LG."� <br /> Property Location: _ City,Village or wnshi County: <br /> /,;iGC%S NiR (6He+W /.?E i� ,c., ji k': c:T.•T <br /> Lot Number: Blk No.: Subdivision Name: Neare oa Lake or Landmark: State Plan I.D.Number: <br /> /�' C44-777 P"41" A (If assigned) <br /> TYPE OF BUILDING <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 IS ecif ) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: • i L`S (-L',1e�. r ,E': /•'C=. <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): N� New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> -? 7 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> W 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: Signaturg: MP/MPRSW No.: Phone Number: <br /> � L-G.-`� t!::�'^�'l�`TC '1.1...�°`--' �-t�-c ,- -i-<-"�— �f� �'f,� `r✓ (r�� 1�`S".tr�`�. <br /> Plumber's Address: Name of Designer: <br /> fes ` , 2f L{ iE~ial LL' S `/ _,( A!�C � t'j rr <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuin A ent: Fee: Date: Sanitary Permit Number: <br /> ' APPROVED // <br /> �Gr oZ ❑ DISAPPROVED Ebb 3 <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. <br /> DISTRIBUTION: White-County,Canary-Bureau of Plumbing,Pink-Owner,Goldenrod-Plumber <br /> DILHR-SBD-6398(N.03/81) <br />