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B ,` '-_ f State and County State Permit # 33.2. <br /> P L. 6 Permit Application County Permit # _73204 <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 /> 'D AY Q,t65 °A , 11 ,-D A ti3 GI?" ; (A) 1 S SYe r) <br /> B. LOCATION: 5-�'/< 5 -.J/, Section /f , T !(?,I, FV,6 {--er r) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township r f'/el.-4741) <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family •..\-- Duplex No. of Bedrooms c7Z No. of Persons <br /> D. TYPE OF APPLIA Dishwasher .(' YES NO Food Waste Grinder YES (-}NO # of Bathrooms—z"" <br /> Automatic Washer ES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY S Q Total gallons No. of tanks l <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) /S-2► J5-31/ Total Absorb Area _30 sq. ft. <br /> New ;\-- Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. Trenches_ <br /> Seepage Bed: Length '3 'Width ,67, Depth Tile Depth IOW No. of Lines _ v. i, <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land f 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 ified Soil Tester, <br /> NAME (i44 t i A! gj C'Y s 0,v C.S.T. # 3 /S- and other information <br /> obtained from (owner/builder). <br /> Plumber's Signature /1,LL Li-'' g�MP/MPRSW# ``� 5-WY Phone A6 r <br /> jr- <br /> Plumber's Address Ld...e Gri..,/:� <br /> I <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> j.0Cr4-r 6N' <br /> I/0 AC gT N <br /> C / <br /> ?c, <br /> Z I <br /> ,// , <br /> ,t,' 4)*) / / i <br /> I <br /> IA;e[..L- m&'Sr 3 <br /> 2 4 G C/}T 2 '4--C' L f- i <br /> 2-c' F00.4 $ pTiG v°Fluic <br /> 1 i o,4✓1 Pe14/arid <br /> C C l .a A <br /> Do Not Write in Space Below - FOR DEPARTMENT U az9NLY <br /> Date of `plication Co --4/—77 Fees Paid: State/(' County/___ Date <br /> Permit O► Rejected (date) d ' — ' Issuing Agent Name <br /> Inspection Yeso 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 6/1/76 <br />