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PLB67 State and County State Permit # �30 <br /> Permit Application County Permit # <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 /> J�eR D aNf}Ifv� 2/ 4N� Sv �I�1tiC- sr/W(>4 : 1k SV/© <br /> B. LOCATI N: /< �(,S '/,, Section L T N, R <br /> f^-}erj W Lot# City <br /> Subdivision Name, nearest . road, lake or landmark Blk# Village <br /> Township �1QiVJCS <br /> C. TYPE OFOCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family �_ Duplex No. of Bedrooms , No. of Persons-Z <br /> D. <br /> ersonsZD. TYPE OF APPLIANCES: Dishwasher YES -- -�-NO Food Waste Grinder YE$,N-NO # of Bathrooms_ <br /> Automatic Washer YES ></NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7�C Total gallons No. of tanks _�_ <br /> *Holding tank capacity 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 11 2)_:S- 3) -'5-Total Absorb Area sq. ft. <br /> New,e< Addition Replacement *Fill System <br /> Seepage Trench: No. Lin Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length_Width Depth �)/Tile Depth�—No. of Lines 7- <br /> Seepage Pit: Inside diameter Liquid Depth Tile SizeL,,2___ <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 Certified Soil Tgster, <br /> NAME V %if./ �G���d/�' C.S.T. # 5,5- AsY;6'and other information <br /> obtained from &94.11 pow 1.% - owne builder). <br /> Plumber's Signature MP/MPRSW# S 745� Phone 406e <br /> Plumber's Address A r .X-1 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> CLi T 4C <br /> f� <br /> �Iv '- L,'—mss 4�F1?iGAC <br /> S&0p <br /> Lice <br /> Zo <br /> Do Not Write in Space Below - FOR DEPARTMENT U J�NLY <br /> Date of lication /-5�2� Fees Paid: State�County Date <br /> Perms Issued/ ejected (date) -s-Z9 Issuing Agent Name <br /> Inspection Yes ✓No Valid# Date Recd <br /> �. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> (pink copy) 4. plumber (canary copy) <br /> Revised Date 6/1/76 <br />