Laserfiche WebLink
p State and County State Permit <br /> , . Permit Application County Permit # 9y93 <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 /> i 1 G Arr 1 V f, 1 J C c3a � c. � � fhc �. IF r' �: � I fe 45tcr lc <br /> B. LOCATION: u. % %, Section T_0 N, R /4L 9 qLd W Lot# 18 City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> A ( r S T_F( Township f G <br /> C. TYPE OF OCCUPANCY: Commercciiaal "Industrial 'Other (specify) Variance <br /> Single family L/ Duplex No. of Bedrooms No. of Persons <br /> D• SEPTIC TANK CAPACITY otal 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 �C Replacement Alternate (Specify) <br /> Seepage Trench: No.of kineal Ft. Width Dgpth Tile depth (topjNo.of Tre hes <br /> Seepage Bed: Length « y Width <br /> Depth_,. Tile depth (top) No.of Lines <br /> Seepage Pit: Inside diat �er Liquid Depth No.of Seepage Pits <br /> Percent slope of land �� o Distance from critical slope <br /> WATER SUPPLY: Private Etloint❑ 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 Cer ied Soil Tesrr, <br /> NAME c r i c r C.S.T. # 1_ and other information <br /> obtained from r el owner/ uilder). <br /> C f. _S y Phone # U6 4 3 <br /> Plumber's Signature _ P/MPRSW# / <br /> Plumber's Address <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 /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY �p <br /> Date of AnDlication 5A&do, _PF,1YF1 Fees Paid: State /�/ County a/ Dat <br /> Permit Issue Rejected ( te) 2ifzv.2 g, 0,f/ Issuing Agent Name y�,,e �src t!1. �,�.✓ <br /> Inspection Yes No _Y�_ State 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) <br /> Revised Date 7/1/78 <br />