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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 (PL13 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 81h 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 /> Pr party Owner: Mailing Address: <br /> I0 0 h-,e r s I r Yd s 1r • 67 101'!y Ohl e is lX <br /> Property Location: Township: County' <br /> Sk,4 Y< SWY<S /YJil N/R �(� 1b(or) W v4�i�, QK BVrKp <br /> Lott Number: Elk Noi <br /> : Subdvisign/Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> I <br /> 4/4 <br /> T Ric '1 / S C �T%—A , .To 4 Q (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-INSTEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY (1 VX x <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: tA1C <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE I ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): X New ❑ Replacement ❑ Experimental �Rl Seepage Bed ❑ Seepage Pit <br /> 3 (1 El Alternative (specify) ❑ Seepage Trench <br /> Water Supply: 19 T a Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> (9 Private ❑ Joint ❑ Public <br /> I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> N of P//umber: �( S' e: �j MP/MPRSW No.: Phone Number: <br /> odrr�c J'Cc� S 03 p 7/T 866' <br /> Plumber's Adder ss: Nam Desi er. IV <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing A ant: Fee: Date: Sanitary Permit Number: <br /> ,O AlAPPROVED <br /> / ,� --.?7-A1:1pp DISAPPROVED S 6 / SOS <br /> ason for Disapproval: t, Its <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 (R.07/81) <br />