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PL6 7 State and County State Permit # AV <br /> Permit Application County PerfijRt # <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 /> fk t'\ E hSen SSC I E /0 a i) J S <br /> B. LOCATION: ', ( /,, Section , T N, R4:4_,E (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township <br /> /� Ih �rvq 441T <br /> C. TYPE OF OCCUPANCY: "Commercial `Industrial `Other (specify) 'Variance <br /> Single family y Duplex No. of Bedrooms No. of Persons cl– <br /> D. SEPTIC TANK CAPACITY / e� y : 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--{ Total Absorb Area --t7-sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No. of Trenches <br /> - <br /> Seepage Bed:—k Length- a ��Width ca$j—Depth3�; '' Tile depth (top) No.of Lines <br /> Seepage Pit: Inside diamejer Liquid Depth No.of Seepage Pits <br /> Percent slope of lands Distance from critical slope <br /> WATER SUPPLY: Private �oint ❑ 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 C ^itisf Soil Tester, <br /> NAME tj'C r` ( (h 14*4 L^ n r tJ S C.S.T. # L1/ 7 and other information <br /> obtained from 09 C in �c v wner uilder). <br /> Plumber's Signature JS v )l MP MPRSW# C) v J Phone # At S(/S–? <br /> Plumber's Address t STrr i <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 to FOR COUNTY AND STATE DEPARTMENT U NLY <br /> Date of A cation e s Paid: State Cou t D e <br /> Permit Issued/ ejected da e) Issuing Agent Name <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 />