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DEPARTMENT OF ' . ' _', APPLICATION �_ SAFETY&BUILDINGS <br /> INDUSTRY �,1 l i FOR SANITARY "til RECEIVED DlvtstgN <br /> LABOR AID �Y } PERMIT • ' ED BOX 7969 <br /> HUMAN'RELATIONS �� - t (PLB 67) �� `} 4 i MADISON,WI 53707 <br /> . JUL 20 7982 <br /> Attach plans for the system on paper not less than 8'.4 x 11 inches in size. Include a plot plan that is deed or drawn to scale. Horizontal <br /> and vertical elevation reference points must be shown. All appropriate separating distances and physical c • ' .-•. in chapter <br /> H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by t.e E. eQ • PWlaster <br /> Plumber,the date,signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be <br /> included. <br /> Propernc Owner: Mailing Address: P <br /> Property Location: gl+i+.s TownsKi Coun : <br /> /VG✓'/a/Vim 33 T 6 fib R/O E (sow `, 7 ti-.�✓.✓ t_�4A/dC <br /> Lot Number: BIk 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 NEW REPLACE- OTHER <br /> GALLONS OF TANKS CO\CRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY APOC) V <br /> HOLDING TANK CAPACITY Arc 2 "V �. , r✓ D.,, . O. <br /> LIFT PUMP TANK/SIPHON CHAMBER Spe, -.NJ <br /> MANUFACTURER: X9),1► + /?, , <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA <br /> (Minutes pe clb PROPOSED(Squar feet): ❑ New Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit <br /> i,,,, <br /> 4P-3 -2-7 7 f/ :3-�' //0.2,5 El❑ Alternative (specify) ED Seepage Trench <br /> Water Supply: Owner's Name as Listed on Soil Test Report(If other than present owner): <br /> pg 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: , l / Sig�yy�� MP/MTV No.: Ph re umber: �' <br /> ,lr/.' ,Jq-e1 ,6171 -1 441 Lida ;v' 5 's -- >a g s/o y <br /> Plyymber's Address: Arne of Designer: <br /> I f,e�N SmubI4 ?ri i uj is 53Sl�Sy �A c,1,,, 1Irpf? 3,27_3 <br /> COUNTY/DEPARTMENT USE ONLY•Signature • Fee ) �p Date: �j p APPROVED <br /> I Permit umber: <br /> Vr /+9723-09g DISAPPROVED 805 <br /> Reason or Di pro v : ¢^ -o^ ©, <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(N.03181) <br />