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,_ <br /> _. <br /> P L B 6 7 " i State and County State Permit # 5-1 <br /> 1,431v <br /> Permit Application County Permi # i <br /> � for Private Domestic Sewage Systems County eu r vie <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 /> 6 Le-t.bN G. ,( Ezso,./ 17/6 /03 6.9t.vE A/E. 04 p4'5 A7,t/, <br /> B. LOCATION: 5C4-) '/4 4/40 Y4, Section l3 , T 'YUN, R /j E (or) W Lot# h.t.42City <br /> Subdivision Name, �/ nearest road, lake or landmark Blk# Village <br /> Oec-4-r+�� -2 V o-to}'fo la 2 V a_4Co Township ff�ClGSOA/ <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family k Duplex No. of Bedrooms No. of Persons X <br /> D. TYPE OF APPLIANCES: Dishwasher YES x NO Food Waste Grinder _YES_)NO # of Bathrooms_a, <br /> Automatic Washer AYES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 75-0 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 .X Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) (12) T 3) ,(Total Absorb Area 4!/5/ sq. ft. <br /> New Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length .,3 Width i Depth 3(0 Tile Depth 2cf-- No. of Lines 3 <br /> 4 et <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land /$4/0 rill 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 /�p p7 ,,- // ,f1/4 Z_ C.S.T. # '�?2. and other information <br /> obtained from W ,O. fel (ewrier'bui'der). <br /> Plumber's Signature - '-? ` 10/MPRSW# �3C)7Z Phone #2 -3s-0? <br /> Plumber's Address Th4l/Zytlq-' / tA9i' 1-1 k'y-U <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> 2o' <br /> • <br /> lg--e/ r <br /> 4 <br /> h /s1 <br /> �s til —A <br /> 2291 3q' Fro <br /> /7,fit//?GY1 it- if <br /> /!I. <br /> !Sr <br /> e�a.- 1)0 <br /> - 54c- <br /> Do Not Write in Space Below OR DEPARTMENT E ONLY ,. <br /> Date of Application '7—/ —7? Fees Paid: State Count Djto /'7� <br /> Permit Issued/11407 'l 22d (date) `7- 70 Issuing Agent Name,/, / ' <br /> No Valid# to Rec'd <br /> Inspection Yes [/ <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 />