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_,..., . <br /> P L B -~� f State and County State Permit # 557/ <br /> ' Cl Permit Application County Per it # <br /> (a <br /> t for Private Domestic Sewage Systems County U rr) <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 /> •0111 ‘J4>tsSe 7 tl Z- L/Alcc,C.A/ 1)-aF 5'4 34-vz_ v►im/ S 5'oS— <br /> B. LOCATION: S tiL/" '/4 St() %, Section 1 (7 , T '/[ N, R ( f ar} W Lot# City__ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township Sfo,SS <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family )T Duplex No. of Bedrooms 3 No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES A- NO Food Waste Grinder YES c-Nr1VO # of Bathrooms" <br /> Automatic Washer 'YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY /00 0 Total gallons No. of tanks _ I <br /> *Holding tank capacity Total gallons No. of tanks `- <br /> New Installation Addition_ Replacement Prefab Concrete -T <br /> *Poured in Place Steel Other (specify) _ <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 3 2) II 3) Total Absorb Area (G � 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 SZ Width / Z Depth 270 Tile Depth Z No. of Lines 2---' -> <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land S 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, ,�/cy <br /> NAME O6 -7' /VC A6LC C.S.T. # 7 / 7i- and other information <br /> obtained from (owner/builder). <br /> Plumber's Signature itC✓` 7-1��-`-- MP/ PRSW# Phone # <br /> Plumber's Address LAJ 1�t.4 c 8-91* <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> -3L1 A-ceE s I T- g 0 IS / E 4 A E <br /> Al 41 <br /> Ii , <br /> 421),, 11 <br /> 5 Life <br /> s2 , <br /> ti <br /> Do Not Write in Space Below - FOR DEPARTMENT US ONLY _ <br /> Date of Application .,—5 7' Fees Paid: State / -- County D to i" <br /> Permit Issued/Rejected (date) �--5—7g Issuing Agent Name Z It 1/2 UM-Q <br /> Inspection Yes No Valid# D'a'te 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 />