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PLB67 State and County State Permit <br /> 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. 0 NER OF PROPERTY Mailing Address: <br /> Za ! r! 5 / rIr <br /> B. LOCATION: ' '/4 t/ /<, Section o2 T N, RIk j' (or) W Lot# —City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village _ <br /> Township FL..1/S $ <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family 4(— Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES IX NO Food Waste Grinder YESk' 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. EFFL$<7- NT DISPOSAL SYSTEM: Percolation Rate 1) 1.3 2) /-r3) :_Total Absorb Area $- $ sq. ft. <br /> New Addition Replacement *Fill System z1 <br /> Seepage Trench: No. Lin. Feet / Asr Width Depth y Tile Depth A;) No. of Trenches <br /> Seepage Bed: Length Width Depth Tile Depth No. of Lines <br /> 'r I <br /> Seepage Pit: Inside diamet r�--Liquid Depth Tile Size <br /> Percent slope of land b7 � 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 ied So'I�T ster, <br /> NAME Pr 1' do A7 S C.S.T. # and other information <br /> obtained fromown uilder). <br /> Plumber's Snature igMP/MPRSW# S I Phone # <br /> Plumber's Address F9 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances yn �c�\drwith� <br /> H62.20, includingwell). !� <br /> S' <br /> Trcr �•r <br /> A <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY / <br /> Date of Application Fees Paid: State___County to / — <br /> Permit Issued4Re�ed- (date) ��7� 4-Issuing Agent Name <br /> Inspection Yes� i_No Valid# ate Recd <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) Ro,,;*ati nate 6/1/76 <br />