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State and County State Permit # �� <br /> PLB67 Permit Application County Per it # —S �- <br /> for Private Domestic Sewage Systems County <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> -" <br /> _ L/ Ss, 3 27 <br /> /0 �/ ✓ 'At` �T i %/S 40r. el nJ,I �Ir� A*1Ik. <br /> B. LOCATION: %-1 '/4 '/4, Section �, T Jp 7 N, R_If (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township /14`F fit O n <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family x Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES-__XNO # of Bathrooms-1— <br /> Automatic Washer K YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 0 -,� Total gallons No. of tanks <br /> *Holding tank capacit Total gallons No. of tanks <br /> New Installation Addition_ Replacement_ Prefab Concrete X <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) o- 2) al, 3)S- Total Absorb Area_ % 0 sq. ft. <br /> New Addition Replacement *Fill System M 0 `cnC � ys�rrR <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length 17 I Width 4 Depth Tile Depth No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> s <br /> Percent slope of land !t Distance from critical slope <br /> I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, <br /> Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared <br /> by the Ce i ' d it Tester, ��,(( g <br /> NAME GS T {l C /In '/r I OV/J' C.S.T. # �/ / and other information <br /> obtained from ff a 6 x litIm !` (owner/builder). <br /> Plumber's Signature X Q I ✓— MP/MPRSW# Q s Phone # <br /> Plumber's Address f '-Qr <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> _---� uj-& <br /> ( fit <br /> It <br /> i <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY <br /> Date of Application )--77 Fees Paid: State/_County ate 5,--,P�— <br /> Permit Issued/ (date) — — _Issuing Agent Name <br /> I—mection Yes Z,"No Valid# 6'6ate Rec'd <br /> unty (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> \I (pink copy) 4. plumber (canary copy) __ r,tt/76 <br />