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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 8Y: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: t r Mailing Address: <br /> CfGPrt S aTro /I1 OY key Ja v 11ecv <br /> Property Location: Gity-Vi4lat,�gr Towns : p County: <br /> IV — '/4 /T 3 N/R / IV (or) W W vhi c /) lam rnp <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: <br /> Or Y O , IC/J / (If assigned)6 6 / <br /> V O YJL <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public' ❑ Variance' ❑ Other (specify)* Bedrooms: <br /> L 1 or 2 Family "State Approval Required. <br /> TOTAL NUMBER I PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY a O V `x' <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER X' x <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes per inch): PROPOSED(Square feed: New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> ❑ Alternative (specify) ❑ Seepage Trench <br /> Water Supply: J Owner's Name as Listed on Soil Test Report (If other than present owner): <br /> K Private ❑ Joint ❑ Public <br /> 1, the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. <br /> Name of Plumber:LSign re: MP/MPRSW No.: Phone Number: <br /> C c I V th t �+ �l` S /�S) //S <br /> Plumber's Address: - F Name of De igner. <br /> COUNTY/DEPARTMENT USE ONLY <br /> Ca <br /> ature of Issuing Agent: Fee: o Date: Sanitary Permit Number: <br /> rmto ,v�1/ " 50/ /D-S-�3 ❑�APPROVED DISAPPROVED 5/s� aS /1623 <br /> Reason for Disapproval: I Kj <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 />