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P L B 6 7 4140# ` Stat_ar*d county State Permit # <br /> Permit Application County Per 't # _ F <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 P <br /> ROPERTYPROPERTY Mailing Address: / J4inP(, ,�' d t-/3 <br /> �I C l Q r M c 1. 4s -e r% / S f 3 7` 4 d Nf L Jilit L�r /I <br /> � ��� crrr <br /> B. LOCATION: SW 1/4 /r/g '/4, Section f( , T i/(J N, R/S) (or) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark <br /> k Blk# Village y— <br /> K7Q/,PtJO a \Ai p 04 o '1/ ce �/'1- r' — t�^t ! 1�s Township �CI G ,/ S"t /\ <br /> C. TYPE OF OCCUPANCY: *Commercial / Qlndustrial *Other (specify) `� *Variance <br /> Single family x Duplex No. of Bedrooms No. of Persons 7 <br /> D. TYPE OF APPLIANCES: Dishwasher KYES NO Food Waste Grinder YES VNO # of Bathrooms_(.4------ <br /> Washer A YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7 .fC Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition Replacement _ Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) -.2"" 2) a. 3) I... ''7/TTotal Absorb Area 3 sq. ft. <br /> K <br /> New Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile DD/pth No. of Trenches <br /> Seepage Bed: Length A id i Width /e r Depth 3 6 "Tile Depth V No. of Lines - <br /> 5/i/ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land 9 670 -3' - 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 CertifAd S it Tester, <br /> NAME 0 d P I e. - /'4,0 7j''„il c- C.S.T. # ? �? and other information <br /> obtained from /t.)'*`C f`tG/1.- n (owner builder). <br /> Plumber's Signature MP/MPRSVI d 3 G r 7 Phone # N6 ��t .-7 <br /> .) '� �Plumber's Address t..1 - • k?"'"-/� <br /> PLAN VIEW: Provide sketch below of system (include ' ction of slope and all distances in accord with <br /> H62.20, including well). <br /> A) <br /> ., Li <br /> 7 ci <br /> L. d <br /> ,,(11 <br /> I3 <br /> � a f\ .k Li gfra C5? <br /> i <br /> .\f <br /> f <br /> U <br /> -f,,,_, r\ 1J <br /> Do Not Write in Space/ Below - FOR DEPARTMENT U E ONLY <br /> Date of Application 1Q -, i 77 Fees Paid: State � County --� ate <br /> Permit Issued/R d (date) �f —77 Issuing_ Agent Name E1 ,{ <br /> '(/LL <br /> f <br /> Inspection Yes No Valid# ate 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 />