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P L B 6 7 State anti County State Permit # 33-0� <br /> Permit Application County er". <br /> # <br /> --7Z3,7- <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 /> J - <br /> �� / 1 4,P Ifc � rQ UX <br /> B. LOCATION: Lo %, Section cj)ry, T 0 N, RK (or) W Lot# -City _ <br /> Subdivision Name, nearest road, lake or landmark Blk# _ Villag _ <br /> S � �� � � t A Town hip ac SO h. <br /> c-- <br /> C. TYPE OF OCCUPA CYC- mercial 'Industrial 'Other (specify) 'Variance <br /> Single family -X— Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIAIVS: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY_ O _Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks__ <br /> New Installation X Addition Replacement Prefab Concret <br /> 'Poured in Place Steel Other (specify) _. - - - <br /> b <br /> F. EFFLU NT DISPOSAL SYSTEM: Percolation Rate 11 2�3) __Total Absorb Area _ sq. ft. <br /> New — Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width DepthTile Depth _No. of Trenches <br /> Seepage Bed: Length _ Q *_ <br /> 36, Width1�Depth Tile DepthNo. of Lines _ <br /> Seepage Pit: Inside diameter�--� Liquid Depth Tile Si e <br /> �� <br /> Percent slope of land `-' Distance from critical slope <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-1 15 prepared <br /> by the Ce Soil Tt <br /> eser <br /> ied� , / C/ p <br /> NAME O (` "'r _ N'e ( ` C.S.T. # T / �- and other i formation <br /> obtained from Q C .Y r (L (owner bw er . �` SGG- <br /> Plumber's Signature _ MP/MPR s I Phone # �O6- `I �S <br /> Plumber's Addresses �1 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). 1 <br /> Fib; h <br /> obW7 �' /hC <br /> (l SOS d <br /> �PX3f <br /> Do Not Write in Space Belo FOR DEPARTMENT USE ONLY _� <br /> Date of Application Space <br /> s Paid: State�Court Date <br /> Permit Issued4fto wd (date) -2 Issuing Agent Name _ — <br /> Inspection Yes ✓ No Valid# ate 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 6/1/76 <br />