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„,,,, <br /> P L B 6 lm�. <br /> 6 711.,..m,,,,y <br /> "''�lii �- , � State and County State Permit # <br /> WO;•1 Permit Application County ' it i <br /> ,, • ( ' <br /> �,( +�� '° for Private Domestic Sewage Systems County,/- �// 4, <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY Mailing Address: S., (I Tl <br /> C 17 7 I. V' s�� l G�. ,� ,S <br /> B. LOCAT ON: NW % v t'i + C i' �Lt•J C. <br /> /a, Section 7 , T lie N, R /9 (or) W Lot# ty <br /> Subdivision Name, nearest road, lake or landmark Blk# Village Township // <br /> 1) i /4-4.,E /)1 J C” C- <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family ic Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY 7-5 Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete_ __ Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation ?C. Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate ''--7'' `3. Total Absorb Area 5/3 ') sq.ft. <br /> New Replacement. Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft. Width Depth Tile depth top) No.of Trenches <br /> Seepage Bed: �C Length ' V Width (Po Depth �� ' Tile depth (top) "te No. of Lines ,-3 <br /> Seepage Pit: Inside divvrge ter Liquid Depth No.of Seepage Pits <br /> Percent slope of land �(i . `' Distance from critical slope <br /> WATER SUPPLY: Private L 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 Cer ied Soil Test r, �- , J _ <br /> NAME t 4 e, t C. '� i1 / 1 S. C.S # 1- / and other information <br /> obtained from C fi Q h y / -� caner wilder). _ <br /> Plumber's Signature �' 2 4' /MPRSW# S? Phone # Y -�(.) 7 <br /> Plumber's Address (A. _ t f <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 /> • <br /> )o Not Write in Space B ow - F R C UNTY AND STATE DEPARTMENT U E NLY <br /> /ate of Application F s P : State Count Date <br /> Permit Issued/Rejected date) ssuing Agent Name GA , / �^ <br /> nspection Yes No State Valid# Date Rec'd <br /> I. 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 />