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PLB 6 7 State and County State Permit # <br /> �q Permit Application County P 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 O1F� �PROPERTY f_ r 1 Mailing Address: / �— <br /> D10 ,1 HJ vi - C,d I�U �� `�L'{ ,h t r ;d /I �' I W'C h f <br /> B. LOCATION: E % AJ G '/<, Section T yT N, R /,C IF (or) W Int# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> lef rc k �Qh / hr. `� Township C c <br /> C. TYPE OF OCCUPANCY: `Commercial `Industrial /T "Other (specify) "Variance <br /> Single family —.Z-- Duplex No. of Bedrooms 1�11— No. of Persons_ <br /> D. SEPTIC TANK CAPACITY �J^ O 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 Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place_Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Notal Absorb Areay °L sq, ft. <br /> New-Replacement—Replacement Alternate (S3ecify) <br /> Seepage Trench: No. ofLinealFt. Width Depth Tile depth (top) No. of Trenches <br /> Seepage Bed:_�c _Length�WidthDepth—Tile depth (top) ;) (P No. of Lines 3 <br /> Seepage Pit: Inside di meter Liquid Depth No.of Seepage Pits <br /> Percent slope of land Q Distance from critical slope <br /> WATER SUPPLY: Private 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 EH115prepared <br /> by the C;f fied Soil Tester, ``'' <br /> NAME / �p r / L Il C 12 k-► ✓1S C.S. # 7 and other information <br /> obtained from q v / SS owner wilder). <br /> Plumber's Signature MP/MPRSW# .� 0 Phone # Y66 All f 7 <br /> Plumber's Address CT J'F3 <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)/w w - FOR COUNTY AND STATE DEPARTMENT USE_QNLY <br /> Date of Apatication Fee Paid: State Issued/ Na <br /> Cou t <br /> Permit ejected ( ate) Issuing Agent me <br /> Inspection Yes No 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) Revised Date 7/1/78 <br />