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PLB 67 State and County State Permit # <br /> Permit Application County r t <br /> for Private Domestic Sewage Systems Count <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 /> lam)eSle y AtaA 33Y 5;,, Snr%/,»�, 4. s7- Pc w4 e&� . r/ o <br /> B. LOCATION AJ I= % SE /4, Section (y_, T" , R 2,f E (or) W Lot# al City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> let Mt Tre le- Township qG 3cn <br /> C. TYPE OF OCCUPANCY: 'Commercial "Industrial "Other (specify) `Variance <br /> Single family X Duplex No. of Bedrooms 01- No. of Persons_ <br /> D. SEPTIC TANK CAPACITY 7,'rO Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete x Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation X Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. <br /> New X Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft.—Width—Depth—Tile depth (top) No. of Tre hes <br /> Seepage Bed:—_Length---all/ WidthIle' Depth -36," Tile depth (top) a'y No. of Lines <br /> Seepage Pit: Inside diame r —Liquid Depth No. of Seepage Pits <br /> Percent slope of land_ �� "/E� "� Distance from critical slope <br /> WATER SUPPLY: PrivateJoint❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <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 ifie Soil Tester, <br /> NAME C r r 1e '�f ri G /iT-1 n� C.S.T. # 1-12�7 and other information <br /> obtained from w (owner/builder). r/�� <br /> Plumber's Signature I 69 <br /> MP/MPRSW# �� Cs� Phone # —4 <br /> 11,T-2 <br /> Plumber's Address �U S tr L.u/ r . 3' .ff <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not been drilled please indicate. <br /> �Y <br /> w <br /> ell <br /> �1 �cz-)' <br /> to <br /> �V , <br /> Do Not Write in Space B to COU TY AND STAI,.DEPARTMENT USE ONLY <br /> Date of c ion gEs State Cou y e <br /> Permit Issued/ jetted (d e) Issuing Agent Name <br /> Inspection Yes No State Valid# Date Recd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 5371' <br /> 2. state (pink copy) 4. plumber (canary copy) Revised Date 7�� <br />