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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 (PLB 67) MADISON,WI 53707 <br /> Attach plans for the system on paper not less than 8'/z 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 /> Propert Owner: Mail i ng Address: / <br /> WL f 4 w•. 9 4 ri S h n I Mel 1 (a1 t f' h - r/1 /+Iq S•Y7 . <br /> Property Location: Ciiyi-Ki1{eye-or Township: County: <br /> '% �U3i `S Iq/T o N/RI EP(or) W q /1-4 a i, n tip <br /> Lot`Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: <br /> 1 �! t Q (If assigned) <br /> TYPE OF BUILDING N <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedroom <br /> IX 1 or 2 Family *State Approval Required. <br /> TOTAL I NUMBER I PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY (y <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: 'L <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): 7P New ❑ Replacement ❑ Experimental ( 'Seepage Bed 1:1 Seepage Pit <br /> 3 • ❑ 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 /> N e of)Plumber: Si tures MP/MPRSW No.: Phone Number: <br /> t i s k q tris () t i I <br /> Plumber's ddres : .f� Name of Designer: <br /> FII.T .S� 4 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signatureof Is//guing Agent: Fee: or 6-.te - A -ROVED Sanitary Permit <br /> /Number: <br /> L// re6Z) O _.4 APPROVED <br /> Reason 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 (8.07/81) <br />