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PLB67 � State and County State Permit # ✓ <br /> Permit Application County Permi <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 Mailing Address: <br /> ZnaW 230q a 910WOc, . /f' 1, N. S rYO <br /> B. LOCATION: Y, '/,, Section �, TWN, R/�-3r (or) NY Loth# City <br /> Subdivision Name, nearest road, lake or land rk -Btt�?k J Village <br /> kALr Townships ,R Qry <br /> C. TYPE OF OCCUPANCY: Commercial 'Industrial 'Other (specify) Variance <br /> Single family /,— Duplex No. of Bedrooms Z No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES ✓NO Food Waste Grinder YES---NO # of Bathrooms_ <br /> Automatic Washer YES %.. i Other (specify) <br /> E. SEPTIC TANK CAPACITY Total gallons No. of tanks _-►_— <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation L/ Addition Replacement Prefab Concrete <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)Q.L__ 2) Y 3))o�' Total Absorb Area c;?e j sq. ft. <br /> News�Addition Replacement `Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length/?L Width/ 0~ Depth3-O Tile Depth oP-4P " No. of Lines Z- <br /> 4 <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size Y <br /> Percent slope of land d 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 Certified Soil Tester, C <br /> NAME 024. C.S.T. # other information <br /> obtained from Ow F✓' (owner/builder). _ <br /> Plumber's Signature MP/MPRSW# V 24 Phone o -•��// <br /> Plumber's Address 2 t:(9 L.� Y�7 S]� <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> �D Li d <br /> J <br /> /3r U/f Ors 01M ,, I _ - o- <br /> I <br /> t�-Xr S 7�N4 <br /> m o 94-7jit" Z s- fxu++, iou tc <br /> A- ASr ro'- 0• (!n+- <br /> Do Not Write in Spa c Below - OR DEPARTMENT l�S ONLY <br /> Date of Application - - Fees Paid: StateCou ty to <br /> Permit Issued/ (date) 3 <br /> - / _Issuing Agent Name <br /> Inspection Yes //No Valid# Y 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) <br /> Revised Date 6/1/76 <br />