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PLB67 State and County State Permit # <br /> Permit Application County Permitwt # <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 /> ✓g./ 4 r- V �Q b i (V .3 o Imo. JC f oe e /s S - y`�7j <br /> 3 � � c7 R fir, n9s rSt <br /> B. LOCAT ON: ),C '/aE'/o, Section �Dj, T_[ N, R_I_k p (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township j $ <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 GrinderYES x NO # of Bathrooms <br /> Automatic Washer K YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7 c5 U Total gallons No. of tanks <br /> "Holding tank capacity 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 Depth No. of Trenches <br /> Seepage Bed: Length Width L.&_Depth ay " Tile Depth • No. of Lines <br /> �r <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land / 7,—,- r— 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 Tester, <br /> NAME Ric 4 e ri r yoPT—t �7 S C.S.T and other information <br /> obtained from qr o owner/builder). <br /> Plumber's Signature / IPR pp !J d j' J y Phone # P y1� <br /> Plumber's Address U L-O-Z" S c{ 71 r <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> I� <br /> 4 <br /> . a <br /> Do Not Write in SpaFe Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State//�, Coun Date <br /> Permit Issued/R (date) _Issuing Agent Na e <br /> Inspection Yes ✓No Valid# Date Recd <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) Revised Date 6/1/76 <br />