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P L B 6 7ti'Ak ll Ji State and bounty State Permit # <br /> ` Permit Application County Perm # ��'_4 <br /> for Private Domestic Sewage Systems County ea/y-7 <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 /> 301,1 )19 r rt.n s S'7 -S' 7'(t.P sr it/.r , ,� 4 /12 /n01• s' C a/ <br /> E Y. A <br /> B. LOCATION: J" /E '/4, Section r, T S/'N, R /7 (or) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village . <br /> Township q#i i c 1 <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family )( Duplex No. of Bedrooms ._ No. of Persons y <br /> D. TYPE OF APPLIANCES: Dishwasher YES x NO Food Waste Grinder YES xNO # of Bathrooms <br /> Automatic Washer YES Y NO Other (specify) 4--------.... <br /> E. SEPTIC TANK CAPACITY —7S0 Total gallons No. of tanks I <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) J <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) o� 2) 3 3) if TotalAbsorb Area 11J sq. ft. <br /> New )C Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. i Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length Ail Width Width / " Depth 36 " Tile Depth a Y " No. of Lines _ 4 1/ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land '/ Y' ki Distance from critical slope --r <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 C ifie Soil Tester, <br /> NAME Q r r s`c /- Qe 6/rt S C.S.T. # 4. 7 and other information <br /> obtained from ,* 0 M gti't'` Iv I7.S 4fir .guilder►. <br /> Plumber's Signature c—s, MP/MPRSW# 4 0 3-7 Phone # ,r6� qt.1- <br /> Plumber's Address CU-A- "- t4)-'�'C- . ci a f'3 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> I 70 <br /> fr id\ , ...-- <br /> ot,H ir 4. <br /> MN ...,' <br /> if <br /> Lpissilf <br /> - <br /> 1.. G r Lr I <br /> — <br /> Do Not Write in Space,,))Below - FOR DEPARTMENT USE ONLY <br /> Date of Application `7 l�— Fees Paaiid: State/0-- County S — <br /> Permit Issued/Ret eieed (date) -1D--7/� Issuing Agent Name /t <br /> Inspection Yes V No Valid* <br /> Dare 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 />