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- ' ; State and County State Permit # `�/ <br /> P L B 6 7 Permit Application County Perm' # — <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 /> N e/2.-9 Z Is 7`t,9-• i ` -r-, I!;�t4AfTs 8 c/e e-, , LUt' S 3-- -go <br /> B. LOCATION: JU iE '/4 S j,J'/4, Section oZ4' , T 3 7 N, R /7-6.4er} W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township /}/'/1-A.#LA <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family ..( Duplex No. of Bedrooms No. of Persons i' <br /> D. TYPE OF APPLIANCES: Dishwasher YES ,.4-NO Food Waste Grinder YES ---NO # of Bathrooms_f <br /> Automatic Washer A.,--' YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 0 Total gallons No. of tanks I <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation �, Addition Replacement Prefab Concrete <br /> *Poured in Place Steel k Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2) ( 3) ( Total Absorb Area . 2-O sq. ft. <br /> New k Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length Width /,, Depth0 Tile Depth ,.28-' No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size � '1 <br /> 5 Percent slope of land /0 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 Certified Soil Tester, <br /> NAME G f L C.S.T. #5 r (5 7Z/and other information <br /> obtained from ` (owner/builder). r <br /> Plumber's Signature i-01- MP/MPRSW# ,/'? 57r)/ Phone # l� 4'f <br /> Plumber's Address !A)_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 /> t <br /> 6/-4 i 7 F Co <br /> flu m ,p,2/1- >tu ,-tLD <br /> k <br /> /11g/ <br /> 3S <br /> t _Sig <br /> Liti tow. <br /> .14\ <br /> /74 i ,- . , <br /> 171 -&,9 _ __......„- N.. <br /> _ i„.., <br /> .''.c.,,. \\\N„..___________<-. <br /> ___________________________,L, <br /> • <br /> Do Not Write in Space Below/ DEPARTMENT E ONLY <br /> Date of Application ✓✓�fjj Fees Paid: State / Cou DatP,/a <br /> Permit Issued/ (date) /O -3/77 Issuing Agent Name <br /> Inspection Yes I./No Valid# Date ec'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 />