2018/03/26 - SANITARY - SAN - New Non-Press - 10636

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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% 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. Pro rty • wner: {— lv SEPTIC TANK CAPACITY Mailing Address: 7/- j� /�/ !! vv, HOLDING TANK CAPACITY `P i ` I V_ f 3 d S / i� / iC r e LO, y v �p Property Location: ,T - =/a N` t/4S S iT4%0 N/R / 07 C4t�-VTIT ee or Township: County: El(or)W Al /0 � 4 114r01e!( Lot Number: Blk No.: Subdivision Name: Nearest Road, Laky or Landmark: State Plan I.D. Number: �'- - - S( �[ G `w 46, a (if assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: �k1 or 2 Family *State Approval Required. 'ERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 25 Seepage Bed ❑ Seepage Pit _?,)— ❑ 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. Ze o Plumber: S Plumber's A dre JL Name f Designer: _ COUNTY/DEPARTMENT USE ONLY Si nature of Issuing A ent: Fee: Date: _ APPROVED Sanitary Permit Number: 'I (.//I✓ce�' g% ��D '� -`7i' y< ❑DISAPPROVEDi�?i% eason for Disapproval: 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 DILHR-SBD-6398 (R.07/81) TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: 1 'ERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 25 Seepage Bed ❑ Seepage Pit _?,)— ❑ 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. Ze o Plumber: S Plumber's A dre JL Name f Designer: _ COUNTY/DEPARTMENT USE ONLY Si nature of Issuing A ent: Fee: Date: _ APPROVED Sanitary Permit Number: 'I (.//I✓ce�' g% ��D '� -`7i' y< ❑DISAPPROVEDi�?i% eason for Disapproval: 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 DILHR-SBD-6398 (R.07/81)