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DEPARTMENT OF APPL , .ION 3� *Cif <br /> . - �U�!� �; SAFETY�B1�LDtt�S . <br /> iNbusTRy, . i.1,'PP FOR �- ,)1 ,�Y 9�� r , f, Mfg <br /> .LABOtI AND , TV,�r f PERM CLF4��� P.O;BOA ; <br /> .HUMAN'RELATIONS' _ ,r . (PLB 67) 0c, O' - , t ' c�. j•98•" MADISON,Wt 131707" ,4' <br /> Grir <br /> �e,J , :PLUMStNG BUREAU <br /> °Attach plans for the system on paper not less than 8%x 11 inches in size. Include a plot plan that is dimensioned or drawn t. • .!lorizolttbi <br /> . -and vertical elevation reference points must be shown. All appropriate separating distances and physical cheriieltetl>Urcrat 2: In charier' <br /> 1I-63,.Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by,th designer.ldell. ;Metter <br /> ..Plumber,the date,signature and license number must hown. The owners copy or a legible reproduction f the ' bst r •. . ., - be- .'#, <br /> 1. included. D C ` ' <br /> Pro erty Owner: Mailing Address: 6 e (9 <br /> p0 I) ,Q2 S o I� 16-0 1 D ,esIr�3- Rd /l'ladr's 094, 'i•; <br /> Property Lotation: '&s iUaee-or Township: County: /yr <br /> £'/aSE'l4S yiT `J NCR E Ve.-T / nOh D Z i) * v <br /> Lot Number: Blk No.: Subdivision Name: Nearest Road,Lake or.Landmark: State Plan 1.0. <br /> 14 d,`n"I Tee//- I ned) .ax <br /> TYPE OF BUILDING <br /> r <br /> _l mbar' , ' <br /> ❑ Public* ❑ Variance* ❑ Other (specify)" sedrbonn:44 <br /> Q'1 or 2 Family *State Approval Required. <br /> TOTAL NUMBER PREFAB POURED-IN NEW REPLACES OTHE <br /> GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) <br /> SEPTIC TANK CAPACITY 1,rai, / 1./...- <br /> HOLDING TANK CAPACITY <br /> /SIPHON CHAMBER $0D / 1f 4� <br /> MANUFACTURER: r t 8 h 6 y + <br /> EFFLUENT DISPOSAL SYSTEM <br /> PERCOLATION RATE ABSORPTION AREA `' �„ <br /> • (Minutes per inch): PROPOSED(Sgyare feet): ❑ New ❑ Replacement ❑ Expef imental El Seepage Bed ❑ Pit s <br /> /s-a 7 3 74•F Alternative (specify) /77 A LI r)l/ . 0.'Seepage Trench <br /> Waterpply: Owner's Name as Listed on Soil Test Report(If other than present owner): , <br /> 0,4 Private ❑ Joint ❑ Public <br /> }...; <br /> I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. >'` <br /> Igoe of Plumbi' ' Si ature: n a MP/MPR§W No.; Phone Nu l <br /> �0* /"l 7it/�7.) `: a of Designer: z <br /> I1O7 e9,.re_ G1ku,i f 4- s-36 ? w� <br /> COUNTY/DEPARTMENT USE ONLY " <br /> Sign e o Issuing Agen • : Sanitary 41-214 Porn llrpe�ber: <br /> O�V ate: <br /> .6G jDate 5:31-,R4 O ROVED nag <br /> R n r isappro . <br /> • <br /> Alternate course(s)of Action Available: a <br /> Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county Prior to ir+`s. <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.e3ae(N.03/81) , <br />