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State and County State Permit # <br /> Permit Application County Pesjt �=�- <br /> for Private Domestic Sewage Systems County <br /> 'DENOTES STATE APPROVAL REOUIRED <br /> Date Approval Received from State if Required State Plan I.D. +� <br /> A. OWNER OF PROPERTY Mailing Address'. S 3 y <br /> I t 1t'A s s f7 ( h kl e '1 / hy /6/ 3 0 .,e/ s t]- ifl o, Is;. <br /> i,t.l�yr °•/f ,M,n . <br /> B. LOCATION: 5-r- is, YP Y., Section LID , T z 1 N, R[L (or) W Lot= —Cu, �— <br /> Subdivision Name, nearest road, lake or landmark Blkg Village <br /> L Township SC' d / <br /> �e cN F V �.Q 1,�, <br /> C. TYPE OF OCCUPANCY: Industrial 'Other (,Pacify)-'Variance � <br /> Single family )_ Duplex_No, of Bedrooms 3 c No. of Persons .r <br /> D. SEPTIC TANK CAPACITY %,) C, Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons Noof tanks <br /> Prefab concrete Poured-in8lace_ Steel Fiberglass Other (specify) <br /> New Installation x Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete—Poured inPlace—Other (Specify)_ <br /> E. EFFLUEI)IT DISPOSAL-SYSTEM: Percolation Rate' —Total AbsoEP— <br /> —sq.Area�Y1sy. ft. <br /> New �C• Replacement Alternate (Specify) ' <br /> Seepage Trench: No.of Lined Ft. Width Depth—Tile depth (top.L—No.of Trenches_ <br /> Seepage Bed: X Length---3&-- Width ./ Depths[• Tile depth (topt av1No.of Lices3 <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land te) ` to Distance from critical slope— <br /> WATER SUPPLY: <br /> lopeWATER'SUPPLY: Private dolnt❑ 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 Certified Sgd Tester,♦.)� - <br /> NAME r, rh /� �' GS.T. s _y ) and other information 1 <br /> obtained from 0syr,, /h4 PAS y( (o�YbriddeO. p ,y`/ <br /> Plumber's Signature �..-�ti MP/MPRSW= �-3 CV/ Phone # �Wl+— r�(..1 7 <br /> Plumber's Address kl 'r/k'✓•-/.e-.ter <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 /> 4o '7- Til l� 'P <br /> I I <br /> IN <br /> f T <br /> a_ <br /> w T4.1 <br /> l �0 <br /> I <br /> ` • 1 <br /> Do Not Write in Space Bel R COUNTY AND STAT] EOEPARTM ENT USE ONLY\ <br /> Date of Application ees Paid: State Q K/ County ..tit'` /Y Data <br /> PermitIssuetl/Ii(yiN, (oat 1 � Issuing Agent Name_ <br /> Z <br /> Inspection Ves [/ No - ' State Valid# 1 �. <br /> -0ata Recd <br /> I. county (white copy) 3. owner (green- copyl:9 <br /> 2DIVISION OF HEALTH;P. <br /> . state (pink copy) P.O. BOX 309, MAD( <br />-_ . plumber (canary copy) ,_ ^'. <br /> - - —' - - Revised Date 711178 i <br />