2019/01/28 - SANITARY - SAN - Other - 10086

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DEPARTMENT OF APPLICATION INDUSTRY, FOR SANITARY SAFETY &BUILDINGS DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 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. The owners copy or a legible reproduction of the soil test report must be included. Property Owner: TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) Mailing Address: O - HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER Property Location: `j .. 11W t/a%Vi t/a$Jy NSR 1"V &(or�" UITY, V"T'dY r Township: -�''� J County: /_1t TT /T 7/ _.c i>'� Lot Number: Blk No.: Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: 7Subdivision (If assigned) rrt ur nulwlrvU Number of Public* ❑ Variance` ❑ Other (specify)" Bedrooms: 1 or 2 Family "State Approval Required. 411-1 r-rr Lurivl vuaruaALaTQ1tm PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): u New ❑ Replacement ❑ Experimental �epage Bed ❑ Seepage Pit � �p ❑ 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. Name of Plumber: Signtures A ; , P/MPRSW No.: Phone Number: C�G�L ,SC S E3Nc�/2 ,'-c� Plum ers ddress: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Siggatture �ofPss Cgq Agent: / Fee: Date: [� APPROVED Sanitary Permit Number: c./�!/ f c J :L,.i�-G,�i� xT;,�;�% � ,� - ;,r % - ' -< ❑DISAPPROVED '< w " �+",� (.' i, ,1 Reason 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 (N.03/81) TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY O - HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: C ews Toi>r+ r-rr Lurivl vuaruaALaTQ1tm PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): u New ❑ Replacement ❑ Experimental �epage Bed ❑ Seepage Pit � �p ❑ 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. Name of Plumber: Signtures A ; , P/MPRSW No.: Phone Number: C�G�L ,SC S E3Nc�/2 ,'-c� Plum ers ddress: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Siggatture �ofPss Cgq Agent: / Fee: Date: [� APPROVED Sanitary Permit Number: c./�!/ f c J :L,.i�-G,�i� xT;,�;�% � ,� - ;,r % - ' -< ❑DISAPPROVED '< w " �+",� (.' i, ,1 Reason 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 (N.03/81)