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Plb #67 7/71 <br /> Wisconsin Department of Health and Social Services <br /> Division of Health <br /> SEPTIC TANK PERMIT APPLICATION <br /> TYPE OR USE BLACK INK - PLEASE PRINT <br /> A. OWNER OF PROPERTY <br /> ' e Address (Street, City, Zip Code) <br /> .),/t1,11, T LOPS P ll feec /i ‘.' is /f id/ S0 25 6"3 <br /> B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED COUNTY ��t/�-7Tr.-!Chee <br /> CITY VILLAGE <br /> One: VILLAGE LEGAL DESCRIPTION Mjr. ey <br /> / ' 5`` 4 , ` e` ) 3 2 -JP/4. <br /> TOWNSHIP 7 f ArF (Block, Lot, Seo.) L / <br /> C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES No PERMIT NUMBER <br /> D. SEPTIC TANK CAPACITY No GALLONS NEW INSTALLATION I'' (PLACEMENT ADDITION <br /> MATERIALS: PREFAB CONCRETE LOURED IN PLACE STEEL OTHER <br /> NUMBER OF TANKS TO BE INSTALLED: <br /> E. TYPE OF OCCUPANCY <br /> Check One: One or Two Family Residence / Commercial Industrial Other (Specify) <br /> Number of persons to be Accommodated 'f' Number of Bedrooms , <br /> F. APPLICANCES, ETC: Food Waste Grinder --—Y,ESS �-'IT6 Automatic Clother Washer Y'�ES NO <br /> Dishwasher --Pfn NO Automatic Potato Peeler YES ,• pla <br /> OTHER (specify) YES =NO <br /> G. MASTER PLUMBER MAKING INSTALLATION / <br /> Name: /LUtIP*/ A/11,5 /7 Address: LQ <br /> fI i ' <br /> / .S'L es-3 <br /> SIGNATURE OF APPLICANT: -- <br /> License <br /> ^' rte -�v <br /> License Number: MP 44W / 5 <br /> ADDRESS: f ,i4 MP RSW <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. (specify) <br /> NOTE: The Application cannot be considered for filing until all of the above questions are answered <br /> and the fee paid. Agents will forward application, the fee of $1.00 for each septic tank and <br /> the third copy of the permit (canary) to the Division of Health. Checks and money orders should <br /> be made payable to the Division of Health. <br /> COMPLETE OTHER SIDE <br />