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PLB 6 7 State and County State Permit # V <br /> Permit Application County Permi <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. OWNEISaR OF PROPERTY( p �s` Mailing Address: <br /> (,Jl q h�R ' 4 Gd 1 e & 0 /� -e e <br /> �* Y,�t res <br /> t r�ly " 1y <br /> B. LOCATION: ��'/< E '/<, Section J, T LA , R IS-0 (or) W Lot# s1_City <br /> FrSu/bdivision Name, nearest road, lake or landmark Blk# Village <br /> /1 I ! /T4 --4-. C<I'Q r rt Township UCL-r Sr n <br /> C. TYPE OF OCCUPANCY: `Commercial 'Industrial 'Other (specify) `Variance <br /> Single family —C— Duplex No. of Bedrooms to No. of Persons_Z <br /> D. SEPTIC TANK CAPACITY 7 S U 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-Pla-Place_ Other (Specify) <br /> E. EFFLUEfY.T DISPOSAL SYSTEM Percolation Rate Total Absorb Ares / sq.ft. <br /> New x Replacement Alternate (Specify) <br /> Seepage Trench: No.of Li 11 Ft. 1`Vidth Depth Tile depth (top) _No.of Trenches <br /> Seepage Bed: �s—Length—L—.Width Depth�f—Tile depth (top) a y No. of Lines •S <br /> Seepage Pit:—Inside Liquid Depth No. of Seepage Pits <br /> Percent slope of land "�� F P Distance from critical slope ------- — <br /> WATER SUPPLY: Private ❑ Joint ❑ 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 Cer-,tiL ed oil Tester, !/ 7 <br /> NAME S r I �' C• i n S C.S.T. # Z "3 / and other information <br /> obtained from r 1p S — / f ) (owner/builder). L <br /> Plumber's Signature MP/MPRSW# C' �e�,y Phone # f M- yis 7 <br /> Plumber's Address r S (. <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 /> a�u 1 <br /> O 1 <br /> C <br /> IL <br /> Do Not Write in Space 6w R COUNTY AND STATE�PARTMENT USE ONLY 7� 7 <br /> Date of A ication Fees aid: State��County [Jate �f <br /> Permi Issue Rejec d date) Issuing Agent Name <br /> Inspection Yes l� o 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 />