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DEPARTMENT OF _ APPLICATION SAFETY& BUILDINGS <br /> INDUSTRY,--`-' _ = 1 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 separatingdistances and physical characteristics as specified in chapter <br /> H-63. W is. Adm. Code, must be shown. An index page or each page must,be signed, sealed and dated by the designer. It 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 Adtlress <br /> 1`1,401? lene Mems y wT. <br /> Property Location: ,City.Village or Township: County: <br /> Q '/< /T�-ON/R/ E (or W .$'Co 13v 4, 77— <br /> Lot Number: Blk Nq:: Subdivision Name: Nearest Road.Lake o�r,–�Lentlmark: State Plan I.D.Number: <br /> •7 '1. 31 T 1Ne�Ffarr /Yerl c.. .•a ttoo z. !,q LH mfgned) <br /> TYPE OF BUILDING <br /> Numbe'0 f <br /> ❑ Public' ElVariance' ElOther (specifyl' Bedrooms: <br /> 1 or 2 Family 'State Approval Required. -11 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE <br /> OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (specifyl <br /> SEPTIC TANK CAPACITY j0 <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA ��L4ll <br /> (Mmutes Far Inch): PROPOSED AREA feed: my New ❑ Replacement ❑ Experimental Seepage Bed El Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: Owners Negues Listed be Soil Test Report Mother than presentw <br /> oner): 7777-1 <br /> [�1' Private ❑ Joint El Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber Sign tore: MP/MPRSW No.: Phone Number: <br /> C'CJ '1 qe Is 6�,r a yew <br /> Plumber's Atldre :, � Name of Designer: <br /> / �J S'.Mr / l - S7oalvi <br /> COUNTY/DEPARTMENT USE ONLY <br /> signator f Issuing q Fee:----ii� Date: t�yAPPROVED Sanitary Permit Number <br /> SV.�- ,� "CiiDISAPPROVED <br /> Rea for Disapproval: <br /> Alternate courses)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 SBDS398 W.07/81) - ' <br />