Laserfiche WebLink
P L B 6 7 State and County State Permit # E'S 6SU <br /> Permit Application County Per It # 67 <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. OWNE OF PROPERTY Mailing Address: <br /> �oi�f / rah s/a�r <br /> B. LOCATION: /Lou/m., Section Tor, R T.. (er{ W Lot# <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township p <br /> C. TYPE OF OCCU A CY: Commercial 'Industrial _"Other (specify) `Variance 1 <br /> mily <br /> Single faDuplex No. of Bedrooms_ No. of Persons <br /> D. TYPE OF APPLIAS: Dishwasher YES NO Food Waste GrinderYES NO # of Bathrooms <br /> Automatic Washer YES NO Other (specify) _ <br /> E. SEPTIC TANK CAPACITY 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. EE-FLUENT DISPOSAL SYSTEM: Percolation Rate 1 _ <br /> 21 31 Total Absorb Area _--srr ft. <br /> New ' 'm Re lacement "Fill System <br /> Seepage Trench: No. Lin. Feet Wi th_ _ Depth _----Ti+e-- tth- No. of Trenches <br /> ---_. <br /> Seepage Bed: Length Width Depth---Sil.e_ Depth No. of Lines <br /> Seepage Pit: Inside diam®tet------ Liquid Depth___ - Tile Size <br /> Percent_51ope--66f— land Distance from art ,W_ _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 Teste <br /> NAME r W a C.S.T. # 5Y92 and other information <br /> obtained from (owner/builder). <br /> Plumter's Signature Mp/ppp{�ggp+ 377Phone T <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> C � •— Well <br /> go <br /> 75 <br /> Nold i r9 +ank 1lpbo9p,1 <br /> o Prefab dor►ere+E <br /> o Ali k wa.4er W&YVIIA4 <br /> �—� Z �"�"►�4h /�o�e. 'ta 9reu.n� sr�cr faC� <br /> Iv!fti lockiA3 device. <br /> '3 411 fresti air iA/ef /2"0bevV- fra <br /> 90 se8 <br /> e4 h ., <br /> 3S ACRES <br /> r r Lin <br /> Do of Write in Space Below - FOR DEPARTMENT USE ONLY <br /> D e of Application 9 -j -77 Fees Paid: State G County Dale <br /> P rmit Issued/Rajeeted (date) q - ) , -77 Issuing Agent Name <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) <br /> Revised Date 6/1/76 <br />