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�'� .;� � State and County State Permit # <br /> �/ P Permit Application County Pei AAEL <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 p Mailing Address. s� <br /> J-Y,c .s X/ rf I �aS 0 �� 7 Lde. /t/41 �S oc h,sT'rr- /ryh. SS S'a i <br /> 1 B. LOCATION: Vr� %� ;it 1 'G, Section L2 , T O N, R-Z.6f E (or) W Lot# _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> N^ C Township <br /> � < Iy \ K�l� tr,, <br /> C. TYPE OF OCCUPANCY: 'Comm mial 'Ind 1s 71 / 'Other (specify) `Variance <br /> Single family _� Duplex_No. of Bedrooms .Z No. of Persons_ 1 <br /> D. SEPTIC TANK CAPACITY '/S V Total gallons Noof tanks <br /> HOLDINGTANKCACITY Total gallons No. of tanks - <br /> Prefab concrete x Pouredin-Place Steel Fiberglass Other (specify) <br /> New Installation x Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete_Poured-m-Place <br /> /�—Other (Specify)— ' <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate—� �� r�To[al Absorb Ar ea � "' sq.It <br /> New y Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft.—Width—Depth—Tile depth (top No.of Trenches— <br /> Seepage Bed:XLength (- Width 79 Depth _Tile depth (toplt;L (F No.of Line, -� <br /> Seepage Pit: Inside diam er Liquid Depth No.of Seepage Pits <br /> Percent slope of land Q Distance from critical slope <br /> WATER SUPPLY: Private L9-joint D Community D Municipal D -_ <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 tfie Cer - ied Soil lest _ ) <br /> NAME of "/ <br /> e io I if C.S.T # Ll and, other information <br /> obtained from 0erA ep T Gwo oi)der) <br /> Plumber's Signature aV fjr to ,�J�P/MPRSW#. •� 0 4 Phone # �p6— YIS� 1 <br /> Plumber's Address 1Y`% 1 t .t PT <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H6220.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 /> I <br /> 1 <br /> s \ <br /> Is <br /> f <br /> c *' <br /> J <br /> Do Not Write in Space*elofFORCOUNTY AND STAT DEPARTMENT USE ONLYDate of �pglication �� es P id: State F County D tPerm- Issued) electetl ( lisping Agent Name�Inspection Ves NoState Valid# Date Recd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309,,MADISON <br /> 2. state (pink copy) 4. Plumber (canary copy) WI 53701 <br /> Revised Date 7/1/78 <br />