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PLB67 State and County State Permit # <br /> Permit Application County Per ' # <br /> for Private Domestic Sewage Systems County <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan ID. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> 124 Lc7- 464-7 <br /> B. LOCATION: /_'/a Yn, Section , T N, R fir) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> C� L f 7 J'6C45-/ Hyegl!C/27GC13/ �'t g7C'/� /////�--ICTownship. Cry <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family -->—( — Duplex No. of Bedrooms 1;21 No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher _4 YES NO Food Waste GrinderYES XNO # of Bathrooms <br /> Automatic Washer 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 X Addition- Replacement Prefab Concrete <br /> *Poured in Place Steel Other (specify) _ <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2►_33) _Total Absorb Area /0 sq. ft. <br /> New x Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length 5;O!Width �}` Depth �50" Tile Depth � No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of landc� Distance from critical slope <br /> 1, 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 Certifgd�Soil T�ster, _ <br /> NAME � ,,dS A C.S.T. # --,Z/-and other information <br /> obtained from G Gzl� 7'7 (owner/builder). <br /> Plumber's Signature ` MP/MPRSW# 3,30 Phone *Aq- 5,5&y <br /> Plumber's Ad, 4te1 .S-W.2J, <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> g�t <br /> V\ � n <br /> rbfa- <br /> Cl VL41F <br /> 1Nv gjopn qie- <br /> -:73eo 7,�i-n K- <br /> `7YSoD' s ;, <br /> 1 <br /> Do Not Write in Space Bel w - FOR DEPARTMENTSY <br /> Date of Application - - Fees Paid: State -� Cour)tg Date -77 Issued/Re 6594 (date) - Issuing Agent Namee 24- <br /> Inspection Yes_IZNo Valid# to 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 6/1/76 <br />