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DEPARTMENT OF - <br /> APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, 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 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: Mallin Address: <br /> Property Location: City.Village owns i County: <br /> kY.S %S T ff R (or) W �G <br /> Lot Number: Blk No:: I Subdivision Name: Neare t oad, Lake or Land ark: State Plan I.D.Number: <br /> (if assi ned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public" ❑ Variance" ❑ Other (specify)' Bedrooms: <br /> A 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 (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): ❑ New ❑ Replacement E:1 Experimental ❑ Seepage Bed EJ Seepage Pit <br /> ❑ Alternative (specify) EJ Seepage Trench <br /> _] <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 lumber: Sign IV <br /> MP/MPRSW No.: Phe NWmber <br /> h <br /> Plumbe ' Address:Z Z , Name of Des r: <br /> 6G <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si tore of Issuing Agent- Fee: APPROVED Sanitary Permit Number: <br /> n // / r� cs2 <br /> /" GO / 7 —tu J�7 ❑ DISAPPROVED <br /> y3 (.X•� %D lc� � <br /> GZi�r6J /) �r< <br /> R96son for Disapproval: /C <br /> Alternate counsels)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 />