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15/5 <br /> 7 Fjtf State Permit # `..�Ir <br /> PLB <br /> 6 f+�'G iiii,y` '. State and County County Permit # tc <br /> n � Permit Application <br /> ,`4Wit County Rur;lett <br /> ',,Z • for Private Domestic Sewage Systems <br /> h <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 /> William Thomey Rt. 2 Webster, WI 5/+t;2-' <br /> B. LOCATION: SE 1/4 :`' 1/4, Section 29 , T 39 N, R 16 t-'(art- W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township Meeaon <br /> C. TYPE OF OCCUPANCY: "Commercial `Industrial "Other (specify) "Variance <br /> Single family x Duplex No. of Bedrooms 2 No. of Persons <br /> D. SEPTIC TANK CAPACITY 990 Total gallons No. of tanks 1 <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in-Place Steel X Fiberglass Other (specify) <br /> New Installation -'{ Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 4 4 3 Total Absorb Area 0 sq.ft. <br /> New x Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches <br /> Seepage Bed: n Length 35 r Width 18' Depth 26" Tile depth (top) 14" No. of Lines 3 <br /> Seepage Pit: Inside diameter c Liquid Depth No.of Seepage Pits <br /> Percent slope of land 1 � -24 Distance from critical slope <br /> WATER SUPPLY: Private Q Joint❑ 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 Certified Soil Tester, <br /> NAME Edward W. Schroeder C.S.T. # 55421 and other information <br /> obtained from � owner (owner/builder). <br /> — <br /> Plumber's SignaturetZ2e-",--g y! -,^-"'-4 MP/M?PRSW* 330 Phone #349 5364 <br /> Plumber's Address 34 rer, TALI 64x79 463 - 2333 <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 /> 1.1.2)Ei 22,4 E929r( ) <br /> /8r x 35' '..301 A <br /> 3 L1/' e e'.Z' V077- z)2, 2 N <br /> /6,2. e G,7e-- <br /> Ie 1 ilk <br /> '990 SzieL <br /> I ,ate <br /> z <br /> t � 4ii, <br /> I I �spf �1 a, I I <br />