1982/07/05 - SANITARY - SAN - New Non-Press - 10243A

Home Browse Search

DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, - FOR SANITARY 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. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: ��/ �/ / ��./� �©/� 1/FJ /��`�� ' 1L/� 50. Curl /C,6 h��'"" ^a t�7C*%el Property Location: City,Village or Townshig: County: .5&'/4-SW'/4S o29 /T '-&/ N/R /47L E (or Gr f li re /..�VR_,r✓� 7" Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D.Number: /��-- 02- L� C®�`. �l� Ilf assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER L RGLASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER qcx, � X MANUFACTURER: 'r M e . ..ar=•/'&_-, � EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New 2r Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench ro Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public /i,14- 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: S' MP/MPRSW No.: Phone Number: tit < 7- 3d�)7 s)Z44_3'S©; Plumber's Address: Tame of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: - "� jco '^ �� 7 ❑ DISAPPROVED .2.�i d3� {JJ � y3) Reason for Disapproval: �f g aW Alternate course(s)of Action Available: J 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 (R.07/81)