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PLB67 State and County State Permit <br /> Permit Application County Perini # <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 /> A. OWNER OF PROPERTY Mailing Address: <br /> t �,tcT 7RvTV141 j?/ lo.PrF Tff �i �sr_ iiG� « ssia !� <br /> B. LOCATION: Alt- 'G oPR- 1/a, Section A_5 T_WN, R__45'--e (or) W Lot# 1I—City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township QfsL1/� <br /> VtKt.46 1-4Lw OF ✓oyAe4m ��CLLAIo>r <br /> C. TYPE OF OCCUPANCY: Commercial Industrial "Other (specify) a *Variance <br /> Single family _� Duplex No. of Bedrooms No. of Persons T <br /> D. TYPE OF APPLIANCES: Dishwasher YES _D,NO Food Waste Grinder_YES_XNO # of Bathrooms_♦;<Z <br /> Automatic Washer YES_)!�,_NO Other (specify) <br /> E. SEPTIC TANK CAPACITY *f,6_E? Total gallons No. of tanks _L <br /> "Holding tank capacity Total gallons No. of tanks <br /> New Installation Addition_ Replacement Prefab Concrete <br /> "Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 3 2) :�S 3) Total Absorb Area sq. it. <br /> New_` Addition Replacement "Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length Width _Depth �.Tile Depth No. of Lines <br /> Seepage Pit: Inside diameter ' Liquid Depth Tile Size �1f� <br /> Percent slope of land 2 o O 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 Certified Soil Tester, <br /> NAME _ �,� T �: /lie AIE7 G C.S.T. # 169a.. and other information <br /> obtained from AA-A" 4ewuerLlwilder). <br /> Plumber's Signature MP/MPRSW# �07� Phone # ZSr <br /> Plumber's Adity Srf$3 n <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> .la <br /> r 'r gat <br /> �D <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application .�r/00Z-7$ Fees Paid: State /,0 � County ate <br /> Permit Issued/a2hx=cI­ (date) .7��772� Issuing Agent Nam <br /> Inspection YesJGNo Valid# ate Rec'd <br /> 41 <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> 7 et.t. ini M, rn A A ..I.....h... 1........... ........\ <br />