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DEPARTMENT OF APPLICATION <br />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'/2 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: Mailing Address: <br />J� rf u. -e w T�'# r 'T 7% ',(/4/ �S" ooiVe Y 4,/ S s— o <br />Property Location City, Village or Tnwnshio:ounty: <br />Ski N4 SW 1/4S t �T 3 N/ R! N (or) W eWv S l 5u Y Iv e 77 <br />Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br />(If assigned) <br />VC yr OVILVIIVu <br />Number of <br />❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br />�I 1 or 2 Family *State Approval Required. a <br />EFFLUENT DISPOSAL SYSTEM <br />PERCOLATION RATE ABSORPTION AREA <br />(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental T Seepage Bed ❑ Seepage Pit <br />�- �/J� ❑ Alternative (specify) ❑ Seepage Trench <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 Plumber: Signature: MP/MPRSW No.: Phone Number: <br />Plumber's Address: Name of Designer: <br />COUNTY/DEPARTMENT USE ONLY <br />ature of Issuing Agent: Fee: oc Date: APPROVED Sanitary Permit Number: <br />fo�D — F.3 ❑ DISAPPROVED L 33 008G� <br />eason for Disapproval: a <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 />TOTAL NUMBER PREFAB POURED -IN STEEL FIBENEW REPLACE- OTHER <br />RGLASS <br />GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br />SEPTIC TANK CAPACITY <br />pOO <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 ❑ Experimental T Seepage Bed ❑ Seepage Pit <br />�- �/J� ❑ Alternative (specify) ❑ Seepage Trench <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 Plumber: Signature: MP/MPRSW No.: Phone Number: <br />Plumber's Address: Name of Designer: <br />COUNTY/DEPARTMENT USE ONLY <br />ature of Issuing Agent: Fee: oc Date: APPROVED Sanitary Permit Number: <br />fo�D — F.3 ❑ DISAPPROVED L 33 008G� <br />eason for Disapproval: a <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 />