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Plb 67 State and County State Permit # S <br /> Permit Application County Per it # <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 n Mailing Address: <br /> 71 •M .} s LJ L 77/ t /x2-&Lwov ,, Si f%-t, SS%off <br /> B. LOCATION: i4 M, Section , T *YD N, R %i K (or) W Lot# ,_City <br /> Subdivision Name, G `L' 7 nearest road, lake or landmark Blk# Village y <br /> Township T,4 -kx,,,oj <br /> -_-�LaalH ���,i y Ip., A - 0,J /l/ L KAWC <br /> C. TYPEOF OCCUPANCY: 'Commercial *Industrial *Other (specify) *Variance <br /> / <br /> Single family / Duplex No. of Bedrooms 2, —No. of Persons 3 <br /> D. TYPE OF APPLIANCES• Dishwasher YES ANO Food Waste Grinder YES Ao NO # of Bathrooms <br /> Automatic Washer ✓ YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7STotal gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation Addition Replacement Prefab Concrete J <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2)_ 3) Total Absorb Area sq. ft. <br /> New Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length 1174"1 Width /1-O Depthj L z Tile Depth ��o No. of Lines A <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size ' <br /> W/ <br /> Percent slope of land O 7i 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 Certified Soil Tester, <br /> NAME (, , L T (Z cHC.S.T. # 57!;-- VSd and other information <br /> obtained from J. L (owner/builder). <br /> Plumber's Signature _ MP/MPRSW# 5—V L Phone 2 3 I/ <br /> �6• <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H6220, including well). <br /> �J <br /> A t4- <br /> /T <br /> 0 <br /> �,, uEuf fi <br /> _ N <br /> wro�tT rkav ' � � <br /> F� 7 <br /> LtwrY-i ow Cd 4-0. <br /> �has <br /> w6cc <br /> 95=x'' •t <br /> Do Not Write in Space Below - FOR DEPARTMENT US� ONLY <br /> Date of Application 7f'o Fees/Paid: State County D to � 7(a <br /> Permit Issued/Rejected (date) Issuing Agent Name /}/AA(� {� <br /> Inspection Yes_�No Valid# ate 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) Revised Date 3/1/75 <br />