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P LB 6 7 �j`�` 4 State and County State Permit # <br /> v (. Permit Application County Per . # <br /> lam•' ,;(4- 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 /> % q (Ai•-, 0 3 Tr r C)..'c S C., Z''q kp ) <br /> B. LOCATION: 14 /v E '/a, Section , T VON, R /4 © (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township n c/f-44 <br /> C. TYPE OF OCCUPANCY: *Commercial "Industrial 'Other (specify) _"Variance <br /> Single family Duplex No. of Bedrooms 2 No. of Persons 2_ <br /> D. SEPTIC TANK CAPACITY 7cjeeNC3 Total ons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in-Place Steel k 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: ,ercolation Rate ' '" 7 Total AbsoVa Are 67 0 0 ,sq.ft. <br /> New Replacement Alternate (Specify) a _r I F'r / iv ti tw d rY w-e (! <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of trenches <br /> Seepage Bed: -Length Wi Ith Depth_ it- -Tile depth (top) A No. of Lines <br /> Seepage Pit: x Inside diameter 'L� Liquid Depth el C.,- / , No. of Seepage Pits <br /> Percent slope of land -� , Distance from critical slope " <br /> WATER SUPPLY: Private L`tsJoint ❑ 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 CAtifiedj Soil *Tester, <br /> NAME i �` i C /c t$ s IQ I j fi C.S.T. # if 7 and other information <br /> obtained from L O vi 4;?_ ower nbuilder}, p <br /> Plumber's Signature /(c) 2 ‘:�--¢ Q....r. Mp/MPRSW# ®�j J�7 Phone # e7 E IP V7 <br /> Plumber's Address LAY VAC - II a"--Y e re <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 /> 1Q AA) <br /> �( y <br /> Ike, 0 <br /> Ac el.' d r 4;� I <br /> d_c ',az._ X7 ST <br /> faCY <br /> ( `r X f S-17 n,4.c 7 6' C <br /> • <br /> 0IN Iv y Qroa <br /> • <br /> voui-tilli'l <br /> V <br /> Do Not Write in Space B ow FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application ees aid: State County Date <br /> Permi 40' Rejected (date) Issuing Agent Name <br /> Inspection Yes"No State 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 7/1/78 <br />