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• <br /> r (i SAFETY&BUILDINGS DIVISION <br /> it, ,i <br /> 201 E.Washington Avenue <br /> flux 7969 <br /> Madison,Wisconsin 53707 <br /> State of Wisconsin <br /> I)epartrnent of Industry, Labor and Human Relations <br /> APPLICATION FOR THE USE OF AN AT-GRADE SYSTEM <br /> /4_ r _1J4 Sec-tiQn_ L N A..1 <br /> RIZE_(or-)-I1 c�/��s;� /. <br /> Location Township/Municipality <br /> Street Address �7 Subdivision County <br /> Landowner' s Name -- � „/ S-71 �� ��_ �L� �✓/ 5-72 1'�' <br /> Mailing Address <br /> I , the undersigned landowner, make application for an at-grade private sewage <br /> system for the above described premises . If approval is granted, I agree to <br /> have the system constructed in conformance with the plans and specifications • <br /> approved by the Department of Industry, Labor and Human Relations (DILHR) . <br /> I understand that an at-grade system is an experimental private sewage system <br /> and, as such, will require detailed inspection during construction and <br /> monitoring after the system is put Into use. I agree to permit county <br /> officials charged with administering county sanitary ordinances and DILHR <br /> employees , or other authorized persons such as the system designer to have <br /> access to the above described premises at any reasonable time for the purpose <br /> of inspecting the at-grade system during construction or monitoring of the <br /> system. <br /> I understand that this application does not permit me or my plumber to begin <br /> construction. ( If the system is approved, DILHR will send the submitting <br /> party a letter of approval which authorizes construction of the system after <br /> all necessary permits have been obtained. ) <br /> I agree to give notice to any subsequent landowner that an application for an <br /> at-grade system has been made and, If the at-grade system installation is <br /> completed, that the premises are served by an at-grade system. In addition, I <br /> agree to give the buyer a copy of this application form. I will also advise <br /> the subsequent buyer that the buyer assumes all responsibilities stated on the <br /> approved plans and in this document: <br /> Signature of Landowner Date <br /> (Valid only if notarized) <br /> 7 (— h/14�ti Subscribed and sworn to before me this <br /> e>/C__ - (Date: ) <br /> Z.> /°/c-o Notary Public, State of Wisconsin <br /> My Commission Expires: <br /> • <br /> • <br />