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Plb 67 State and County State Permit # �� <br /> Permit Application County Per it # <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 /> T n4A11< 6A pA 5:1 YsA F' 8,4 &#10 sig 3i,v 6 `rte n 41- <br /> 8, <br /> tB. LOCATION: '414V11. '/., Section T_WRly'�'aliiif (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village ,,ll <br /> 1#4-4a &� Township 0A <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family Duplex No. of Bedrooms lm�L No. of Persons__ <br /> D. TYPE OF APPLIANCES: Dishwasher YES _ 7'-,NO Food Waste Grinder YESNO # of Bathrooms <br /> Automatic Washer _ YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 'J Total gallons No. of tanks <br /> *Holding tank capaci Total gallons No. of tanks <br /> New Installation Addition Replacement_ Prefab Concrete <br /> *Poured in Place Steel Other (specify) _ <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2) 3) Total Absorb Area sq. ft. <br /> New Addition _ Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile D,e�th No. of Trenches <br /> Seepage Bed: Length 14Width _��Depth _J$�> Tile Depth No. of Lines eZ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land 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 C ified Soil Tester I 1—� <br /> NAME f-- r' C.S.T. and other information <br /> obtained from (owner/builder;. <br /> Plumber's Signature 1Z a 2MPRSW# � — Phone #— P <br /> PLAN VIEW: Provide sketch below of systemi Jude direction of slope an istances in accord with <br /> H62.20, including well). <br /> 7 J/ <br /> r , <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application s 7 Fees /Paid: State County Date <br /> Permit Issued/Rejected (date) �����1� Issuing Agent Name <br /> Inspection Yes No Valid# Date ec'd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> 2. state (pink copy) 4. plumber (canary copy) <br /> Revised Date 3/1/75 <br />