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. , _ <br /> _.„,.. _ <br /> P LB 67fetaln. <br /> `,rState and County State Permit # /15-1-7'2 <br /> Permit ApplicationCounty Permit # 9 /Y <br /> :`'''r1(: Count <br /> ,(;_yam '' for Private Domestic Sewage Systems Y <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 /> EZZ;07- /144Tt IoM , on/Lrr) co,'s- sY8c / <br /> B. LOCATION: Alf=Y. jc 1/4, Section ,� , T Tc-'N, R /1 E.--4or►CW Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township DeGf/k y <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family )( Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY /66 O Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation X Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate '4 Total Absorb Area '76-0 sq.ft. <br /> New X Replacement Alternate (Specify) <br /> Seepage Trench:_ No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches <br /> Seepage Bed: JC Length 4' ' Width APS Depth .4767" Tile depth (top) .2.2 No. of Lines -3 <br /> Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits <br /> Percent slope of land 2---. Distance from critical slope /VO/V. ' <br /> WATER SUPPLY: Private ®.Joint ❑ 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 Soil Tester, <br /> NAME (34:-C,',4 Tc-)ei y"N. ie C.S.T. # .3a1-`- -Volry and other information <br /> obtained from [`"Caro T fit- .e- , ✓ owner/build <br /> Plumber's Signature (jpu� ' R-w /MPRSW# tfc 6 / Phone #6,15-----f)VV <br /> Plumber's Address 'k "---z[ 44/e4-1 4j, s. .5`v-R- / <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 /> • <br /> • <br /> • <br /> Do Not Write in Spa% Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application Q S// f/ Fees Paid: State /y County .2( Date 5-/ /7 r/ <br /> Permit Issued Rejected D (date) (,v�,,e 5////�/ Issuin A ent Name � � 64 <br /> Inspection Yes No State Valid# Date Rec'd <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) <br /> Revised Date 7/1/78 <br />