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.. _. . <br /> PLB67 ,,.. ,.. <br /> . ,. i State and County State Permit # a✓�� <br /> i <br /> �_ ,Y Permit Application County Per it # — <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: <br /> CS 'r 1 r 'I'_ ' ( 0 X H 0- 1 ; C^ 'P t In1 SAS 7 <br /> B. LOCATION: /Vu: 4 SE Y4, Section /7 , T y/N, R / .7 E (or) W Lot# . City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village , <br /> h 0 0 r rik. tf . r Township ({ it / U Iv-er � <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family V. Duplex No. of Bedrooms o� No. of Persons ca_. <br /> D. TYPE OF APPLIANCES: Dishwasher YES )( NO Food Waste Grinder YES XNO # of Bathrooms—/ <br /> Automatic Washer YES X NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7 s- () Total gallons No. of tanks I <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition Replacement Prefab Concrete x <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) t. 2) 3) 2,. Total Absorb Area V3cL, sq. ft. <br /> New J(, Addition Replacement *Fill System <br /> Seepage Trench: No. Lin Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length .2* Width /$.! Depth a y '" Tile Depth 1 a." No. of Lines . '` <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size S <br /> t <br /> Percent slope of land 0 /O 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 Ce fied f Soil _Tester, <br /> NAME �C d-f.r-i ( k 4 Cp /Ti,r) S C. . # `T '7 and other information <br /> obtained from To S e l t Q K r a e r" (%uilder). u <br /> Plumber's Signature le 0- I MP/MPRSW# 0.? P .5- 7 Phone # s:? _ _T'/ s 7 <br /> Plumber's Address 4 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> A-) <br /> - N. /'1 <br /> !,,,, - <br /> 1, 0 1, / Pt / <br /> k <br /> ti �--i 3 c ' - lC 3 �y-------'--‘...7 <br /> / iNI <br /> a 9 0 ; <br /> 0, / A <br /> Vi <br /> Do Not Write in Spa a Below - OR DEPARTMENT USE ONLY <br /> Date of Application �O--lel Feesee d Paid: State Count ate. Q , — <br /> Permit Issued/l ed (date)/Q 19-'7 p Issuing Agent Nam /�' � <br /> Inspection Yes /VNo Valid# ,1 "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 6/1/76 <br />