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Wisconsin Department of Health and Social Services <br /> Plb. #67 3/70 Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE or USE BLACK INK <br /> A. OWNER OF PROPERTY <br /> Name Address (Street, City, Zip Code) <br /> B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTEDg ALTERED OR EXTENDED COUNTY ... <br /> Cheek one: <br /> CITY VILLAGE LEGAL DESCRIPTION C 1 /CF/f/v'� 7 <br /> TOWNSHIP <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER <br /> D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place Steel Other <br /> NUMBER OF TANKS TO BE INSTALLED: <br /> E. TYPE OF OCCUPANCY <br /> Cheek One: One or Two Family R41Aej6eA Commercial Industrial Other <br /> ff (Specify) <br /> Number of Persons to be Accommodated '— ...w Number of Bedrooms � ^ <br /> F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YESy NO <br /> Dishwasher YES NO Automatic Potato Peeler YES NO <br /> Other (Specify) ' <br /> G. MASTLR PLUMBER MAKING INSTALLATION <br /> r <br /> Name: Address: /4csnse Number: <br /> MP JX04 <br /> Signature of Applicant: MP RSW <br /> Address: <br /> H. (To be Completed by Issuing Agent) <br /> Date of Application Fee Paid <br /> Permit Issued (date) Permit Number <br /> Agent (Name) For: <br /> Town, Village, City, County, etc. <br /> (Specify) <br /> Note: The application cannot be considered for filing until all of the above questions are answered and the <br /> fee paid. Agents will fom.ard application, the fee of $1.OU for each septic taxuc and the third copy <br /> of the permit (canary) to the Division of Health. Checks and money orders should be made payable to <br /> the Division of Heaath. <br /> Do not write in space below - FOR DEPARTMENT USE ONLY <br /> I. DATE RECEIVED ACCEPTED BY RETURNED <br /> (Initials) (Date) See Corres.) <br /> FEE RECEIVED VALID. No. PERMIT NO. <br /> es or No <br /> REVIEWED BY APPROVED DATE <br /> (Initials) Yes or No <br /> COMPLETE OTHER SIDE <br />