2017/11/13 - SANITARY - SAN - New Non-Press

Home Browse Search

DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter 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 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 included. Property Owner: , Mailing Address: Property Location: gy_.Vj lag@ -or Township: County: M' %MEt/aS I T27NSR /(QV(or)W -ec V1 $ &:rs1 F Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: ` State Plan I.D. Number: /Vt-�� (If assigned) Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. EFFLUENT DISPOSAL SYSTEM 'ERCOI_kTION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit f Icr� 0 ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Ylve of lumber:` SinLure: MP/MPRSW No.: Phone Number: 3 �e C_ s _ I�cI (,71s J 6 6 vrsr Plumber's Address; Name of Designer: COUNTY/DEPARTMENT USE ONLY Si ture of�PPROVED Issuing gent: Fee; C Date:. Sanitary Permit Number: aiJa2CQ tP l Z ❑ DISAPPROVED Z ag,5 Figason for Disapproval: j Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White -County, Canary -Bureau of Plumbing, Pink -Owner, Goldenrod -Plumber DI LHR -SBD -6398 (R.07/81) TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER LAS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: Zu C EFFLUENT DISPOSAL SYSTEM 'ERCOI_kTION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit f Icr� 0 ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Ylve of lumber:` SinLure: MP/MPRSW No.: Phone Number: 3 �e C_ s _ I�cI (,71s J 6 6 vrsr Plumber's Address; Name of Designer: COUNTY/DEPARTMENT USE ONLY Si ture of�PPROVED Issuing gent: Fee; C Date:. Sanitary Permit Number: aiJa2CQ tP l Z ❑ DISAPPROVED Z ag,5 Figason for Disapproval: j Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White -County, Canary -Bureau of Plumbing, Pink -Owner, Goldenrod -Plumber DI LHR -SBD -6398 (R.07/81)