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STATE OF WISCONSIN -DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS <br />DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING <br />P.O. BOX 7969 - MADISON, WI, 53707 <br />APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM <br />Location: TownshipiMunicipality: <br />HE SE S IT 14C) N/R 1�- Xgg pix�W Oakland <br />Street Address: Subdivision: County: <br />NA <br />Landowners Name: Mailing Address: <br />Herzl Camp Association Webster, WI 54893 <br />I (We), the undersigned, hereby make application for an alternative system on <br />the above-described premises. Vremfs-es-are riot <br />sui-tIf approval is granted, I <br />agree to have the system installed in conformance with the Bureau's approval <br />of plans and specifications. <br />I further understand that an alternative system is more complex in nature than <br />a conventional private sewage system and as such will require detailed <br />inspection during construction and moniLuring after the system is put into <br />use. I agree to permit both county officials charged with administering county <br />sanitary ordinances and Bureau employes or other authorized persons to have <br />access to the above described premises at any reasonable time for the purpose <br />of inspection the construction of or monitoring of the system. I further agree <br />to either personally or by my agent contact the proper county official to <br />arrange the time and date to begin construction of the system. <br />I understand that this application does not permit me (the applicant) or my <br />agent (the contractor) to begin installation. If the system is approved, the <br />Bureau will send the applicant a letter of approval which authorizes <br />construction of the alternative system after all necessary permits have been <br />obtained. <br />I agree to give notice to any subsequent buyer that an application for an <br />alternative system has been made and if installed, that the premises are served <br />by an alternative system and further agree to give the buyer a copy of this <br />application. <br />The Bureau accepts this application subject to this understanding and subject <br />to all the conditions and obligations set out in this application. <br />77 <br />Signature of Applicant - Date <br />STATE OF WISCONSIN <br />S S . <br />COUNTY OF i %- <br />DILHR-SBD-6413 (N. 05/81) <br />Subscribed and sworn to befo:F. me <br />This__ day of `� ylq i> <br />e Z/�Z, <br />Notary Public, State of Wisconsin <br />My Commission Expires: r <br />