Laserfiche WebLink
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS <br /> INDUSTRY, 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: Mailing Address: <br /> 1 !` Z!FAL J7Nk le . r1006,,1e,4eccl S- <br /> Property Location: f,iiip n! ge-or Township: County: <br /> (,U t/aN4! YsS /S /T 3V N/R Zy jjor(g) /2u-S' LsJi4PIJ A- <br /> Lot Number: Blk No.: Subdivision Name: Neares oa , Lake or Landmark: State Plan I.D.Number: <br /> C7-# , (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> �'for2 Family *State Approval Required. .� <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 06 ✓—'" f� <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER E�# <br /> MANUFACTURER: C <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): ❑ New P9 eplacement ❑ Experimental O'Seepage Bed ❑ Seepage Pit <br /> / i {/0 El Alternative (specify) L:1 Seepage Trench <br /> Water Sup(y: 'Y Owner's Name as Listed on Soil Test Report (If other than present owned: <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 Plumber: Signature: PAP/MPRSW No.: Phone Number: <br /> G'EC: G AI 3L0 $ 6 <br /> Plumber's Address: Name of Designer: <br /> m-,(L <A cc &0:5 c e-- .r 4-- <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: Sanitary Permit Number: <br /> APPROVED / <br /> 25VI/ /._/8�- ❑ DISAPPROVED ,3�'17� ` /e) �3 <br /> Reason 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 /> DILHRSBD-6398 (R.07/81) <br />