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�RTMENT OF APPLICATION SAFETY & BUILDINGS <br /> ,JUSTRY, 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%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 /> Property Owner: Mailin Address: ` <br /> Property Location: City,Village owns i . County: <br /> r'/as '/aS /T 1R (or) W �L <br /> Lot Number: I Blk No:: Subdivision Name: Neare t oad, Lake or Land ark: State Plan I.D.Number: <br /> j�jO C, (lf ass' ned) <br /> TYPE OF BUILDING <br /> Number of <br /> El <br /> ❑ Variance* E] Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. 3 <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY <br /> HOLDING TANK CAPACITY v'BTJ <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED (Square feet): ElNew ❑ Replacement ElExperimental F-1 Seepage Bed ❑ Seepage Pit <br /> ❑ 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 /> Name of lumber: Sign MP/MPRSW No.: Phone tuber: <br /> h <br /> A <br /> a ( y N-'45 <br /> Plumbe ' Address: Name of Dloop- <br /> es' r: <br /> COUNTY/DEPARTMENT USE ONLY <br /> Si ture of Issuing Agent- Fee: , Date: rrtte� Sanitary Permit Number: <br /> / p r{� APPROVED <br /> Zi�rLJ r' ZJ 6O/ -ro`O ❑ DISAPPROVED SSS 6ZZ / Io <br /> Ril6son for Disapproval: X,/ <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(R.07/81) <br />