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P L 6 7 State and County State Permit # <br /> ' Permit Application County PermA # — <br /> for Private Domestic Sewage Systems County l i�lt Y <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY Mailingf Address: <br /> 6>° r". v... 64z -r1 r` I ,) (0 �,p/-e fi �/. ✓1 i c z w L i c,t 1 Yk i i n,. ' / <br /> B. LOCA N: A/6.- '/4 S tji/4, Section '3S,' T S/eN, R / (or) W Lot#v City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> -1 4 Q /ram Township 4C`TSo/�- <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family X Duplex No. of Bedrooms No. of Persons S— <br /> D. TYPE OF APPLIANCES: Dishwasher x YES NO Food Waste Grinder YES x NO # of Bathrooms— <br /> Automatic Washer )( YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY / ).O C`) Total gallons No. of tanks _ / <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation Addition_ Replacement Prefab Concrete X <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area 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 3a ' Width / r ' Depth 36 " Tile Depth a Si zf No. of Lines 3 <br /> ii/ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> c7 / ) <br /> Percent slope of land 4/ L-4=1 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 Cer: ied Soil Tester, ,1 <br /> NAME r t L I % l^ C. 4 3 and other information <br /> obtained from h.0 ^e q r' (owner/builder o3� Phone # �(o(0 5/�� 7 <br /> Plumber's Signature C�--' V. 4. k. MP/MPR�W# / <br /> Plumber's Address L \L '� L S' Se ill <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> ii <br /> / (31 <br /> "--/N <br /> V `.r�` 0 W `F c <br /> J0 ' <br /> v <br /> /0 1 <br /> /1ar3b <br /> '''..---',\ <br /> / rf <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application 2-7g Fees Paid: State /0 County — D to - - <br /> Permit Issued/I d (date) 5 2 -73" Issuing Agent Name ,&' <br /> Inspection Yes ice/ No Valid# to 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) Ro"icarl Harp 6/1/76 <br />