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State and County State Permit # Ara3T <br /> PLB67 *_ Permit Application County Permit j&�; <br /> 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: Pelt, <br /> \0y h �J o h n S e �. o�-� C) S' o� n y, l�/6r �� <br /> B. LOCATION: '/< W Ya, Section T N, R //� (or) W Lot# —City <br /> -T - - <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township AM`e rn d N <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family Duplex No. of Bedrooms eZ No. of Persons D. TYPE OF APPLIANCES: Dishwasher K YES NO Food Waste Grinder YES NO # of Bathrooms— <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY Total gallons No. of tanks ,! <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation Addition Replacement_ Prefab Concrete <br /> *Poured in Place Steel Other (specify) _ <br /> F. EFFLU NT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) _Total Absorb Area 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�Width�Depth " Tile Depth No. of Lines ell <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size V <br /> `, <br /> Percent slope of land 7_O_X;_� 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 Cert' ' d Poil Tes er, <br /> NAME KcJ 4,t C-�Ch G" (,4 T C.S.T. # 7 and other information <br /> obtained from o owne builder).Plumber's Signature MP/MPRSW# d- OI !_ q Phone # f ` y04' 7 <br /> Plumber's Address 9 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> 1 <br /> Tr G,1�ksp <br /> a <br /> R <br /> � Xav � la <br /> 4g ry <br /> V�AJCf/tny • <br /> v <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) n.,« F/1 i7a <br />