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� ,itn,. a <br /> P L B 6 7 :>4 <br /> (., ,„r ,4 State and County State Permit # <br /> It� �i) Permit Application County P r 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 /> B. LOCATION: Ai 'At '/a, Section Z T37 N, R I , E (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township kli /4PrIL .p <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family ..-\-- Duplex No. of Bedrooms 2— No. of Persons <br /> /WC3/Cr jit-tide C <br /> D. SEPTIC TANK CAPACITY 7 t Total 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 otal Absorb Area sq. ft. <br /> New .) Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches <br /> Seepage Bed: is.-- Length 3 ' Width /2-- Depth 3<0, Tile depth (top) Z., No. of Lines "a---- <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land Distance from critical slope <br /> WATER SUPPLY: Private 'Joint ❑ 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 Certified Soil Tester, <br /> NAME 'Pry GIbN7 t I 6(ei2r C.S.T. # — 2 3 and other information <br /> obtained from` (owner/builder).� <br /> Plumber's Signature kn o� MP/MPRSW# /).l? S 7t[f Phone #Z76— ir <br /> Plumber's Address C.l.s,32-6-e Gild <br /> 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 /> Do Not Write in Space - OR COUNTY AND STATE DEPARTMENT U 3 ONLY <br /> Date of Application Fe P id: State County %A • Dat ,/ Z <br /> Permit Rejected ( at �V Issuing Agent Name Aj. C <br /> Inspection Yes No A State 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 7/1/78 <br />