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v.= <br /> • <br /> -r~,' � State and.County� State Permit # / /�� <br /> PLB67 - <br /> Permit Application County Petr it # — ," <br /> for Private Domestic Sewage Systems County - . J <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 /> a) arvt �'-�' I ‘ �� �t( 1,a.lee £g-s7/ <br /> B. LOCATION: ,4P(3 '/4 $E Y4 Section.�,3 , N, R/5 $ (or) W Lot# 7 City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township L.a. n//e 'e <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family // Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher/4/p YES "NO Food Waste Grinder YES '-IVO # of Bathrooms_L <br /> Automatic Washer YES i/NO Othe (specify) <br /> E. SEPTIC TANK CAPACITY 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 Other (specify) _ <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 6 2) 3) 3 Total Absorb Area. �/p 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 y/' Width /o' Depth 43° Tile Depth J0 f` No. of Lines ' , <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land /a- 90 Distance from critical slope A4/ — <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 L�Hc z;4/ /(/ez,se'Xf C.S.T. # SS ^ 4 '( and other information <br /> obtained from /P, /64044/4--47 �ewner •uilder <br /> Plumber's Signature au:)' M?/MPRSW# Phone #��5` ,� Q <br /> Plumber's Address / z'7 a 95/Y4-44 .c'A,- - ,-S,s/r>/' <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> 4/0 <br /> le <br /> „c ,-s- <br /> /2P° <br /> CAe iv <br /> 111 . I <br /> ?0 1 CT 11 \I � <br /> L <br /> Do Not Write in Space Below F R DEPARTMENT SE ONLY <br /> Date of Application /0—)6----7-10. Fees Paid: State ��County ate g <br /> Permit Issued/Beeeted (date) /Q 67g Issuing Agent Nam <br /> Inspection Yes l-No Valid# J�`/P1 ate 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) Revised Date 6/1/76 <br />