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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 (PL1367) 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 /> Pro t Ow er: Mailing Address: =y-- <br /> fc � <br /> Property Location: Ct[y"4�'i1�2go-or Township: County:,p <br /> I /T qC^ N/R Iq 9,(or) W s' c e <br /> Lot Number: I Blk No.: Subdivision Name: Nearest oad, Lake or Landmark: State Plan I.D. umber: <br /> A' / / ✓'C S / �� (if assigned) <br /> TYPE OF BUILDING Y� 4 <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> C(c TOTAL <br /> LLONS OF TANKS CONCRETE POPLA p IN STEEL FIBERGLASS INSTALLATION REPLACE-NEW M NT (SSpec fy <br /> OTHER <br /> GA ) <br /> SEPTIC TANK CAPACITY �C <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER 7S-X:� <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): EX New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> n ElAlternative (specify) ❑ Seepage Trench <br /> Water Supply: 7 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;7 cf Plumber: Sign MP/MPRSW No.: Phone Number: <br /> Plumber's A ress R Name of Designer: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issui' g �r Fee: E P_X7_1"y <br /> te: <br /> j APPROVED S <br /> anitary Permit Number: <br /> �� ❑ DISAPPROVED 7 (//�S 7 <br /> ason 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 /> DI LHR-SBD-6398 (R.07/81) <br />