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PLB 6 7 State and County State Permit # � <br /> Permit Application County Permit # <br /> for Private Domestic Sewage Systems County le5l"I'u2rl- <br /> `DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # �� G 7 9 / <br /> A. OWNER OF PROPERTY Mailing Address: <br /> KCJ l LU't 454r- �i 3C <br /> B. LOCATI N: w '/< �'� '/,, Section 3 T ( N, R_/L—& (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township J-r; <br /> C. TYPE OF OCCUPANCY: `Commercial 'Industrial "Other (specify) 'Variance <br /> Single family _4-- Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY Total gallons No. of tanks <br /> HOLDING TANK CAPACITY ` Total gallons No. of tanks ) <br /> Prefab concrete Poured-in-Place Steel_ < Fiberglass Other (specify) <br /> New Installation Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft Width Depth Tile depth (top) No. of Trenches <br /> Seepage Bed: Length Width �-- - --Depth _-_of Lin __` <br /> Seepage Pit. Inside diameter Liquid Depth No. of Seepage Pits — <br /> Percent slope of land Distance from critical slope <br /> WATER SUPPLY: Private &int ❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <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 oil Teste , <br /> NAME rJ7 C.S.T. 7 and other information <br /> obtained from 4e owner/buil <br /> Plumber's Signature MP/MPRSW# C? S�-2r Phone # <br /> Plumber's Address G <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not been drilled please indicate. <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State /<,-/ County -:1 /� Date <br /> Permit Issued/Rejected (date) J/ Issuing Agent Name �-'6/ k <br /> Inspection Yes '__No State 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 7/1/78 <br />