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PB 67 State and County State Permit <br /> Permit Application County Permit # 1 �_ <br /> for Private Domestic Sewage Systems County -L"4� <br /> ~DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY <br /> ++ Mailing Address: <br /> nQ�re C�1 rz5n/o c �7 /t 1�h r /� 1 ? <br /> B. LOCATION. �(L/,�,��/,, Section 2Q, T_9QN, R14L)('(or) W Lot* _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> R5/e,- Zdd• p0 Y�Township ��pP <br /> C� L <br /> C TYPE OF OCCUPANCY. Commercial Industrial Other (specify) 'Variance <br /> Single family _Yk Duplex No. of Bedrooms Z-2. No. of Persons <br /> D. SEPTIC TANK CAPACITY 7U 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 /> - -- <br /> E. EFFLUENT DISPOSAL SYSTEM: percolation Rate -�i_Total Absorb Area -- <br /> sq. ft. <br /> New�Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft. Width Depth—Ti le depth (to ) No. of Trenches <br /> Seepage Bed: Length 23" WidthI P�_Depth ?.(42 Tile depth (top) No. of Lines 3 <br /> Seepage Pit:--Inside,did�eter Liquid Depth No.of Seepage Pits <br /> Percent slope of land_ T/4 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 175 prepared <br /> by the tified Soil Tester, \ <br /> NAMEitf '-7� f, T /�lotiU C.S.T. # 41V T and other information <br /> obtained from < ilder <br /> Plumber's Signature MP/ P # '0497,2— phone <br /> Plumber's Address —� <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 /> Asa <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of A lication / Fees Paid: State /Z/ County Dated <br /> Permit ssued ejecte (date) / P/ Issuing Agent Name��) sazzzzft <br /> Inspection Yes No , )c_ 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) <br /> Revised Date 7/1/78 <br />