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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 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 /> Propert Owner: Mailing Address: <br /> Le w Nrr7-eJ DeCA4 e Y 7:LL 4 *d.s"a <br /> Property Location: City,Village or Tow! nshin: County: <br /> ,$E '/a 44 '/aS o 39 NiR 114 * (or) W We, S/ �1I, �' V ire <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number: <br /> (If assigned) <br /> TYPE OF BUILDING <br /> Number of <br /> ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: <br /> 1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN STEEL FIBER - NEW REPLACE- OTHER <br /> GLASS <br /> GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY -7 t p `-- <br /> HOLDING TANK CAPACITY <br /> LIFT PUMP TANK/SIPHON CHAMBER <br /> MANUFACTURER: <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA roe <br /> (Minutes per inch): PROPOSED(Square feet): New ❑ Replacement ❑ Experimental I� Seepage Bed ❑ Seepage Pit <br /> 3 ❑ Alternative (specify) ❑ Seepage Trench <br /> 'aog <br /> Water Supply: Owner's Name as Listed on Soil Test Report (lf other than present owner): <br /> L, 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: Signa re: MP/MPRSW No.: Phone Number: <br /> G r9 v 1 S a /✓ LLO, . 5f 5I i'3 (G3 s)` — a y gT <br /> Plumber's Address:r� Name of Designer: <br /> S//3 9^/ S / wZ 5���e 1 <br /> COUNTY/DEPARTMENT USE ONLY <br /> Sign a of Issuing ent: Fee:[�-+j� Cp Date: p APPROVED Sanitary Permit Number: <br /> J Ur � O 3.- ❑.DISAPPROVED S' <br /> p*gason 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 />