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P L B 6 7 State and County State Permit # " <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. OWNER OF PROPERTY Mailing Address: j h1 r�l n• S j <br /> � s <br /> tr4 f'k —r. w Q y S01 Fii--ederrc A- Pirwv <br /> B. LOCATION: L✓w_'/4 A)L- '/4, Section , T q ON, R E (or) W Lot# ty_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township T( r AJC i. <br /> C TYPE OF OCCUPANCY: Commercial 'Industrial ^ 'Other (specify) 'Variance <br /> Single family -K— Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste GrinderYESXNO # of Bathrooms- <br /> Automatic Washer X YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY S Total gallons No. of tanks <br /> "Holding tank capacity Total gallons No. of tanks <br /> New Installation Addition_ Replacement_ Prefab Concrete_ <br /> "Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) /6'2) 3) 0 Total Absorb Area sq. ft. <br /> Newx_ Addition Replacement "Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Depth Tile Pepth No. of Trenches <br /> Seepage Bed: Length ,Width _Depth °^ 7 Tile Depth la No. of Lines13 <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> �- y <br /> Percent slope of land / /0 , Distance from critical slope Q <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 Soil Tester, - <br /> NAME o w i U to C.S.T. # Ll3 7 and other information <br /> obtained from Kmel v r P (owner/builder). q �p6/� y <br /> Plumber's Signature tt MP/MPRSW# L7 3O S / Phone # d - /If -7 <br /> Plumber's Address S qdl 91 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> I ` <br /> 6q1 <br /> o <br /> U -�4'c7ry <br /> 3 <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY <br /> Date of Application /�-�1 es P id: State:_Co my tem <br /> Permit Issued/13 t (date)/j -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 /> '--ate (pink copy) 4. plumber (canary copy) <br /> -- \ Revised Date 6/1/76 <br />