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P B 6 7 State and County State Permit <br /> r u v V Count P it if _� <br /> L Permit Application V <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 /> I <br /> de <br /> fo <br /> B. LOCATION S_%.S t 'L, Section � T� N, R 14 g (ori W Lot# _City _ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> t Township $c.o_1— <br /> X�OFs1U�—!� <br /> C. TYPE OF OCCUPANCY: °Commercial *Industrial 'Other (specify) 'Variance I <br /> Single family ��_ Duplex No. of Bedrooms . No. of Persons .3 <br /> D. TYPE OF APPLIANCES: Dishwasher _YESNO Food Waste Grinder_VES VNO # of Bathrooms-/— <br /> Automatic <br /> athrooms_/Automatic Washer_t,,�VES_NO Other (specify) <br /> E. SEPTIC TANK CAPACITV_j_QO-0_Total gallons No. of tanks j <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) _)_ 21 I 31 _I_Total Absorb Area_Sp.Qsq. ft <br /> New_L,�Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet_� ' Width .=&' Depth; Tile Depth �No. of Trenches c <br /> Seepage Bed: Length ,;X Width ZO ° Depth 3 G „ Tile Depth ;a-V " No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size `f � I( <br /> Percent slope of land O Distance from critical slope j]An•�_ <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 r7��afie Soil Tester, _. <br /> NAME l C.S.T. # ss Sri 6 and other information -j <br /> obtained from n '� (owner/builder). - <br /> Plumber's Signature _ ° MP/MPRSW€ Phone <br /> Plumber's Address Cl_ <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with ' <br /> H62.20, including well). <br /> Al <br /> i <br /> O <br /> 0 <br /> S <br /> C <br /> I t ( •� t5• ��, <br /> .__ . F. .'•_ -x _. I t - � + _.,.: 1-..�. .} 's ti :.;_moi <br /> 41 <br /> 'SS <br /> S `I <br /> t a <br /> I <br /> Do Not Write in Spac�e �qelo FOR DEPARTMENT USE ONLY <br /> o..m afari/ -y� � Fe P d: State 90County — D e '' <br /> Permit ssuea/lett r/1/def Issuing Agent Name <br /> Inspection Ves No Valid# Date Recd - <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 5370 <br /> 2, state (pink copy) 4, plumber (canary copy) ( <br /> Revised Date 6/1/71 <br />