Laserfiche WebLink
P State and County State Permit # . <br /> Permit Application County Per it # — - <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 7-PROPER)TY -- /� Mailing Address: <br /> �ohw f y h Lrr S /Gr' � a L/ Qkik� �J <br /> W1Sr- <br /> B. LOCATION: _AZF—'/< AIVJ I/, Sectio _T, T N. R_ (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village ______ <br /> VAP llOTownship <br /> W �Ulr'e <br /> C. TYPE OF OCCUP NCY: gComm rcial "Industrial 'Other (specify) 'Variance <br /> Single family 77 Duplex No. of Bedrooms No. of Persons_ <br /> D. TYPE OF APPLIANCzS: Dishwasher YES NO Food Waste Grinder—YES YNO # of Bathrooms <br /> Automatic Washer X YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7S 0 Total gallons No. of tanks <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. <br /> EFFLUENT DISPOSAL SYSTEM: Percolation Rate 11 2) 31 S Total Absorb Area sq. ft. <br /> New n Addition Replacement 'Fill System <br /> Seepage Trench: No. L � p� Width Depth Tile 0))th No. of Trenches <br /> Lin. Feet <br /> Seepage Bed: Length 8 V, Width JL—Depth Tile Depth No. of Lines 3 <br /> Seepage Pit: Inside diameter� Liquid Depth Tile Size <br /> Percent slope of land / t 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 Ce w d it Tester. /, 7 <br /> NAME r f o S C.S `7`�/ and other information <br /> obtained from 0 G yr owner/builder: <br /> Plumber's Signature yy# tJ' CQ / Phone # <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> /777 <br /> �G. C) <br /> ftj <br /> YIl© cd C. efY <br /> Do Not Write in Spacpy Below FOR DEPARTMENT USE ONLY <br /> Date of Applicationn—/5�7j � Fees Paid: State Count ate <br /> Permit Issued/F3yeoteel (date) `j`/J~— _Issuing Agent Na <br /> Inspection Yes lI�No Valid* Date 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 6/11/76 <br />