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Plb 67 `Xi% State and County' State Permit # <br /> . °j,* Permit Application County Permit # <br /> for Private Domestic Sewage Systems County <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required J '/ ) -state plan I.D. # 7.5' — I) d o 3 h <br /> A. OWNER OF PROPERTY Mailing Address: <br /> P'i it (' ,p _ . <br /> roi. 4c' ,_ cScar ( t- aas i- J co 6sI4, r w ' c s—Yce9.,? <br /> B. LOCATION: A ,/1/4 Si= /,, Section a.c. T t/o N, R /s I (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# SG A. I .4r ,4 tillage <br /> Township fq .. jT'soti <br /> C. TYPE OF OCCUPANCY: *Commercial X *Industrial *Other (specify) Li.;f�Varjance <br /> Single family Duplex No. of Bedrooms / No. of Persons 11 e Kra, <br /> D. TYPE OF APPLIANCES: Dishwasher YES )( NO Food Waste Grinder YES 4-NO # of Bathrooms_ <br /> Automatic Washer YES X NO Other (specify) <br /> E. SEPTIC TANK CAPACITY p1 Y Q 0 Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition Replacement Prefab Concrete /r <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) .2,,/tv, Qd.?3► 0I0Total Absorb Area 9 / 4._ sq. ft. <br /> New X Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of. Trenches <br /> Seepage Bed: Length 38' Width a.'y Depth q f"Tile Depth 36 No. of Lines 5 <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size „ <br /> Percent slope of land d "lo S 6 Distance from critical slope •••---1- <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 Certi ed Soil Tester, L' <br /> NAME w o dr j c j\ z7 vg ea.n S C.S.T. # ti 7 and other information <br /> obtained from Pt 7`fo• <br /> a sty 4,-, r (owner/builder). p <br /> Plumber's Signature . 4-t r I c J 1 fi i 0 'il r MP/MPRSW# d 0 09 Phone # 0`6 Li ,, eA <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> V <br /> 4\ <br /> 1Q� r <br /> Co t)`r <br /> , <br /> ,,..1 <br /> 0 ,. , v , <br /> . _________---___ <br /> ( .c. <br /> ) / , <br /> j as q ►a: X <br /> 4. <br /> , ,, ,, t CN <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State County Date <br /> Permit Issued/Rejected (date) Issuing Agent Name <br /> Inspection Yes No Valid# Date 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 3/1/75 <br />