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P L B 7 _,, ,_. <br /> 61,,,,,As,,,,,,, <br /> " , ., State and County State Permit # <br /> ' 1) Permit ApplicationCounty Per t # <br /> :,�' (" for Private Domestic Sewage Systems County <br /> mot,,.— <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWER OF PROPERTY Mailing Address: <br /> /9i^R I col %1'C NAk /N 0 A it t7 u i' LLf i' J c - <br /> B. LOCATION: S"E '/4 -.N',A.' 1/4, Section 7 , T `� N, R ice' (or) W Lot# City <br /> Subdivision Name, nearest road, lake or la�dmark Blk# Village <br /> f <br /> Township J 4 C ul,.i c/^ <br /> (..� /C` t-t J <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family )c` Duplex No. of Bedrooms No. of Persons <br /> D• SEPTIC TANK CAPACITY _Q 11rtTotal 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 I - / - I Total Absorb Area 6 y(? sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of ineal Ft. yNidth Depth Tile depth (top) No. of Trenches <br /> Seepage Bed: K Length �G Width ' '' Depth -�C '' Tile depth (top) .Q No.of Lines <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land 0 �� Distance from critical slope <br /> WATER SUPPLY: Private IS�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 Cer 'lied ,Soil Tes r, �'t' S Jr / 7 C►1 ,(�G "`e <br /> NAME 73E tl ✓" C.S. # O a-3 ) and other information ► <br /> obtained from 8c^_ LIZ . 6-`Q c b\ r\ owner/• ilder). 7 / <br /> Plumber's Signature ��'t� ��-c 1 , • "-•> MPLMPRSW# ei'� vv Phone # s-i/l�`7 <br /> Plumber's Address LA "o 4.4L� i. -t .S ii of• t <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 /> • <br /> )o Not Write in Space B o OR COUNTY AND STATE DEPARTMENT <br /> )ate of • •-.,ication Paid: State — Cou t D t <br /> 'ermi Is ued 'ejected date) Issuing Agent Name <br /> nspection Yes No State Valid# Date Rec'd <br /> . county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> ?. state (pink copy) 4. plumber (canary copy) <br /> Revised Date 7/1/78 <br />