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P L B 6 7 state and County State Permit # obs E/ <br /> L Permit Application .County Permi 2 <br /> for Private Domestic Sewage Systems County —�(d.Cl2 <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 /> CtlAn[cs xjwer4 7,"E60 CtliS- Sv68Y <br /> B. LOCATION: zFE X_/v0,6' %, Section /(p-, T.3_ N. R/3� 6.--len) 0 Let* _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township 9,6W� ✓ <br /> C. TYPE OF OCCUPANCY: Commercial 'Industrial 'Other (specify) 'Variance <br /> Single family _X Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher -YES —NO Food Waste Grinder—YES—NO # of Bathrooms-2. <br /> Automatic Washer_YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY—LGO Total gallons No. of tanks —/ <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation Xe Addition Replacement Prefab Concrete le <br /> 'Poured in Place Steel Other (specify) <br /> r <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Hate 1) -/ 2)—L3) _l Total Absorb Area_(p/T sq. it. <br /> New X- Addition Replacement_*Fill System ' <br /> Seepage Trench: No. Lin. Feet Width_DepthTile Depth No. of Trenches III <br /> Seepage Bed: Length'' Width LO ' Depth Tile Depth�l�_No. of Lines , <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size_y' . <br /> Percent slope of land_&,P Distance from critical slope-,go/ <br /> I, the undersigned, do hereby certify that the information 1 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 _(�CJG zh C.S.T. # and other information <br /> obtained from [�iGFr F / �builde rL <br /> Plumber's Signature 120"a .. up/MPRSW# Phone #6aS ?A o <br /> Plumber's Address-db 1'. 1 Py1ELG LA/CE ryR 7/ <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). -I <br /> — <br /> t <br /> —j—� <br /> i � 4-4— <br /> i ILTi ; LTi 1 <br /> i <br /> Do Not Write in Spa e B y9w FOR DEPARTMENT U/gE ONLY J s <br /> Date of Application �/- (p- - Fees Par State /L Cou ty D <br /> Permit Issued/Rejere& (date) Issuing Agent Name <br /> Inspection Yes_kf--6c` Valid# pate Recd I <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701.1 <br /> 2. state (pink copy) 4. plumber (canary copy) <br /> _ ` - Revised Date 6/1/76 <br />