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^r_ . <br /> ' � State and County State Permit u <br /> Permit Application County Permit a <br /> PLB 67 6✓v <br /> for Private Domestic Sewage Systems County �wr^" <br /> DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. S <br /> A. OWNER OF PROPERTY Mailing Address: <br /> GrJ,�.-rz_� ZL a E azo ,� oni ne. ss /NG Eiveu�s��t/ <br /> B. LOCATION: f tY• xe %' Section z7, T N, R E (oi W Lot= _City <br /> Subdivision Name, nearest road, lake or <br /> 7/zlandmarkB(lk/.L>�Q/ <br /> Village <br /> Township _S"f,l1r <br /> MotA25I iar25- <br /> C. <br /> TYPE OF OCCUPANCY: 'Commercial 'Industrial 'Other (specify) "Variance <br /> Single family _Yj DUPle% No. of Bedrooms No. of Persons_. <br /> D. SEPTIC TANK CAPACITY 71;v Total gallons No. of tanks_ <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in Place Steel X Fiberglass Other (specify) <br /> New Installation Y, Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete_Poured in-Place <br /> '' Other (Specify)_ <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rale Notal Absorb Area—�'' sq. It <br /> New "/ Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft.—Width—Depth—Tile depth (tog)—No.of Trenches_ <br /> Seepage Bed:—LLength,;Z Width-.8 _Depth�,4­,� Tile depth (i No.of Lines �S <br /> Seepage Pit: Inside d; met r--,.Liquid Depth No.of Seepage Pits <br /> Percent slope of land �-� Distance from critical slope <br /> WATER SUPPLY PrivateDint Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 it 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 EH115prepared i <br /> by the C d Soil Te r ' <br /> NAME r C,S.T. 471' and other information <br /> obtained from owner/builder <br /> Plumber's Signature /MPRSW>' 3077- Phone at 3Sb 9 <br /> Plumber's A.ddrees <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well Ioca. <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 /> I - <br /> Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY_��_� - <br /> Date of Application As-,1W Fees Paid: State /`/ County X/ Date <br /> Permit Issued Rejectetl ocaten ' i ,/!'b/- issuing Agent Name 25,1 " ,_,S�{�-��� 1 t\ <br /> Inspection Ves_No.;,, State ValitlA 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 />