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i."- f State arx Goarrt�y State Permit # <br /> Permit Application County Permi # <br /> Vi ; �� <br /> for Private Domestic Sewage Systems County n <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 /> WI'a Am /114t4WA/ '42 i27; 60k'ss1W-re 9 ' <br /> B. LOCATION: Sit- 14 S 1%, Section // , T*b N, R /y E--(or) ( Lot* City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township Sec 7T _ <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family x - Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 75 ) Total gallons No. of tanks / <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) / 2) Z. 3) .2 Total Absorb Area •5//© sq. ft. <br /> New X Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length 0 //I Width /c ' Depth ,i, i" Tile Depth /e9 4 No. of Lines .i <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size 77``/6 <br /> Percent slope of land cf,® Distance from critical slope /VO/VC <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 t c, 4. jGeV,r9 /kit C.S.T. # ,$` - 14 ,' and other information <br /> obtained from &j!t / 0-4!AN.V owner/builder ) <br /> Plumber's Signature (.'2e / ,.e_f r..� 111FP/MPRSW# -i�=6'/ Phone #moo J�g37 /e, <br /> T -- J <br /> Plumber's Address IT po'1�'.ct 1.4/e4— 4"1/8"7/ <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.z0, including well). <br /> /N- 41d ` l <br /> A cke s ' i c_'9k <br /> 1 'lam- <br /> I , / 0/44 <br /> .v f <br /> 1 ` ` <br /> • <br /> - ' - <br /> Do Not Write in Space Below OR DEPARTMENT USE ONLY _� '� , <br /> 7-13 � ` <br /> Date of Application Fees Paid: State/� — County g <br /> Permit Issued/ / (date) i"i �3 _Issuing Agent Name <br /> Inspection Yes L. No Valid# to Rec'd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> state (pink copy) 4. plumber (canary copy) Ro,,;�o.a nnta F,/1/76 <br />