Laserfiche WebLink
Plb 67 tr`~--�y',�.i State and County State Permit # <br /> Permit Application County Perm # _ 0 <br /> for Private Domestic Sewage Systems County 1 'i/T 1& <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY Mailing Address: SS</ /A <br /> . (/ v I^ >I ,e l.Q ) e* /4, r 414 7 /41deh D►-ILi1. 1L cI 1h , vyri ; n ,' <br /> B. LOCATION: Sr'/4 /4f LJ4, Section 10, T S/1 N, R /.,5-2( (or) W Lot# aS/.r City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township 7-Q C KrSC i, . <br /> C. TYPE OF OCCUPANCY: omOlercial *Industrial *Other (specify) *Variance <br /> Single family X Duplex No. of Bedrooms y No. of Persons s— <br /> D. TYPE OF APPLIANCES: Dishwasher YES y NO Food Waste Grinder YES )'NO # of Bathrooms <br /> Automatic Washer ' YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY / a U t Total gallons No. of tanks 1 <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation Y Addition Replacement Prefab Concrete X <br /> *Poured in Place Steel Other (specify) <br /> F. EFFL NT DISPOSAL SYSTEM: Percolation Rate 1) a. 2) 2- 3) aTotal Absorb Area 3 A y sq. ft. <br /> New Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. f Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length id Width If' Depth 26 "Tile Depth ,, 9 "i No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> y " <br /> Percent slope of land Distance from critical slope <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 ed Soil Test <br /> NAME 0 vise r t t,-7 �,o t r) t C.S.T. # 7 .7 and other information <br /> obtained from 4,q%; h � jl J,Q p' (owner/builder). p <br /> Plumber's Signature Zkci--e4.."... . C , ,v� MP/MPRSW# 0 C v Phone # det — qtJ *7 <br /> PLAN VIEW: Provide sketch below of systemi (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> r S' ' <br /> Ai <br /> LF <br /> ff4 , <br /> Ya <br /> • <br /> • <br /> l,x (,, <br /> TH , <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY —^ ` <br /> Date of Application (, -5-7 , Fees Paid: State / CountyDate (�'--S 76' <br /> Permit Issued/Ra}esled (date) 6-5--7ro Issuing Agent Name <br /> Inspection Yes /0' No Valid# to Rec'd <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) Revised Date 3/1/75 <br />