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DEPARTMENT OF s 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 8Yz 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 /> Ow /S <br /> Property Location: or To ip: Co nty: <br /> bob �t/aS iT N/R -9(or) W aC n �yrit <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> /V v 4 O /A-1 (if assigned) <br /> TYPE OF BUILDING 1 <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> L$1 or 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 Q ) <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feet): 1;8 New El Replacement El Experimental Seepage Bed ❑ Seepage Pit <br /> 3 q -1 ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: T t— Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> 1K Private ❑ Joint ❑ Public <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Nam of P umber Si re: MP/MPRSW No.: Phone Number: <br /> Plum er's Address: Nam esig er: <br /> 1 <br /> V <br /> COUNTY/DEPARTMENT USE ONLY <br /> Signature of Issuing Agent: Fee: Date: APPROVED Sanitary Permi Number: <br /> ❑ DISAPPROVED 4�2O$2 <br /> eason 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 /> DILHR-SBD-6398 (R.07/81) <br />