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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 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: Mailing Address: <br />J <br />p ,— G w ' li <br />Property I-ocation: City, Village or Township: Coun y: <br />'/aga '/aS 13 /T,,T,? NSR E (or)® f< s <br />Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br />6 _ . J (If assigned) <br />TYPE OF BUILDING <br />Number of <br />❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br />IETI or 2 Family *State Approval Required. 3 <br />EFFLUENT DISPOSAL SYSTEM <br />'ERCOLATION RATE ABSORPTION AREA P" <br />'New per inch): PROPOSED (Square feet): P IVew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br />/D ❑ Alternative (specify) ❑ Seepage Trench <br />nater 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: SignatMP/MPRSW No.: Phone Number: <br />, ,.D i2 �--_� .,, �--� _ _ z -, * 1% 1 ( 7j$ _ 7,4 r-,.' <br />of llesigner: <br />COUNTY/DEPARTMENT USE ONLY <br />Slqnalure of Issuing Agent- Fee::CC,Date: APPROVED Sanitary Permi Number: <br />DISAPPROVED 7�� llS�s <br />R son for Disapproval: <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 <br />GALLONS OF TANKS CONCRETE <br />POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER <br />PLACE INSTALLATION MENT (Specify) <br />SEPTIC TANK CAPACITY <br />HOLDING TANK CAPACITY <br />LIFT PUMP TANK/SIPHON CHAMBER <br />oe <br />MANUFACTURER: r <br />EFFLUENT DISPOSAL SYSTEM <br />'ERCOLATION RATE ABSORPTION AREA P" <br />'New per inch): PROPOSED (Square feet): P IVew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br />/D ❑ Alternative (specify) ❑ Seepage Trench <br />nater 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: SignatMP/MPRSW No.: Phone Number: <br />, ,.D i2 �--_� .,, �--� _ _ z -, * 1% 1 ( 7j$ _ 7,4 r-,.' <br />of llesigner: <br />COUNTY/DEPARTMENT USE ONLY <br />Slqnalure of Issuing Agent- Fee::CC,Date: APPROVED Sanitary Permi Number: <br />DISAPPROVED 7�� llS�s <br />R son for Disapproval: <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 />