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PLB67 State and County State Permit <br /> Permit Application County Per # <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 /> Ate?OWNER OF PROPERTY Mailing Address: <br /> B. LOCATION: _jj/ '/< 1►7 '/<, Section T90 N, R-/' E I..) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Cr7yLC3' 7 179LF/7IGGn7 rCtLf,9JN� v!//e'jCTownship,`J�G S(t>7 <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_YESNO # of Bathrooms— <br /> Automatic Washer-YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7S0 Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition_ Replacement_ Prefab Concrete <br /> *Poured in Place Steel X Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3 3) Total Absorb Area /© sq. ft. <br /> New x Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length 3C'Width �}° Depth ';011 Tile Depth 8'F No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size 4 " <br /> Percent slope of land ;/� Distance from critical slope <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 Certifr&' dSoil <br /> NAME � ,-� �'���'� C.S.T. # 15's_y-qLand other information <br /> obtained from LGr n (owner/builder). �/ <br /> Plumber's Signature ' MP/Mill _ 3 j O Phone *--3*1— S,SGy <br /> Plumber's Addrass <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` - 75L <br /> C -E wnr " s 2 stz IC- <br /> tf,� <br /> �ol <br /> _l - <br /> s�-z-p�e�3� <br /> ,;o1L but /�F� PLm`0 _cuc� > toQ .3�,X/y ' <br /> r <br /> Do Not Write in Space Bel w FOR DEPARTMENTSly E ONLY <br /> Date of Application — — Fees Paid: State ID 1 Couryty Date f — <br /> Permit Issued/R94 (date) _Issuing Agent Name (--f <br /> Inspection Yes��ND Valid# to Recd <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 6/1/76 <br />