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:0„,.,. <br /> P L B 6 7 r # State and County State Permit # <br /> Permit Application County Per t # — <br /> "--j_0*.i <br /> for Private Domestic Sewage Systems County IU rs <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 /> I <br /> �, 4� r,1 w I ie f co--e S 7; r— wfAc , c:— �y� <br /> B. LOCATION: Mme, 1/4 S"k!, 14, Section X, T a9 N, R /6 ' (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> S T'T 7 j 3 Township Al`e`e t 6 � <br /> C. TYPE OF OCCUPANCY: *Commercial 11,dustrial *Other (specify) *Variance <br /> Single family lc. Duplex No. of Bedrooms / No. of Persons ( <br /> D. TYPE OF APPLIANCES: Dishwasher YES x NO Food Waste Grinder YES )(NO # of Bathrooms_I <br /> Automatic Washer YES X NO Other (specify) <br /> E. SEPTIC TANK CAPACITY '`J S' L Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation )C Addition Replacement Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLU NT DISPOSAL SYSTEM: Percolation Rate 1) .� 2) 3) ...... Absorb Area of / 0 sq. ft. <br /> New '. Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length ea C ` Width /a' Depth ,3 , i I Tile Depth a S/ n No. of Lines vL /I <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size .* <br /> Percent slope of land d `-- Distance from critical slope i'------- <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 Ce ed .Soil,�Tester, L! <br /> NAME a0 Olt e~ t c r Fi�/iS C.S. # T 7 and other information <br /> obtained from 4 p' . R t N v I:e own• %uilder). <br /> Plumber's Signature �� MP/MPRSW# (n e9 �7 Phone #f 6- 59/.-`7 <br /> Plumber's Address W' c • t/S 4 3 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> A) <br /> a 4 /0 �� <br /> l <br /> LI X / <br /> 11 <br /> iS <br /> S�L Bir C�i <br /> `3 <br /> )o Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application 3-3O-77 Fees P id: State/b -- Count/ f Date .*•—7 i <br /> Permit Issued!. .eeted•- (date) — Issuing Agent Nam' 7 �! <br /> nspection Yes l•- No Valid# G' Date Recd <br /> I. 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 6/1/7S <br />