Laserfiche WebLink
6 �P1_B f+�E L} State and County State Permit # 2 <br /> I . V, ,�� Permit Application County Permit `�// <br /> ('�'` ( for Private Domestic Sewage Systems County Al,,a::p,.-4, " <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 /> /(a r , 1s,' n 4 q •�' n o 0 r 7 y �:'c , tiI ) r A(.1 4 ,itti ,. tS s-117 <br /> B. LOCATION: PLO '/4,S 1/4, Section 7, T 40 N, R 16 E (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village j <br /> Township O o if"1.Q n d <br /> Dm' ),' &s 4a Iry <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family X Duplex No. of Bedrooms v'— No. of Persons <br /> D• SEPTIC TANK CAPACITY S 0 Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete X' Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation X Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons/ y Prefab concrete Poured-in-Place Other (Specify) <br /> Z E. EFFLUTT DISPOSAL SYSTEM: Percolation Rate . ' Total Absorb Area g 'O� sq.ft. <br /> New J( Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal.a Ft. 4.,`Width laepth Tile depth (t p)ti—No.of TrgAches <br /> Seepage Bed: X -Length a 7 Width Depth �6 Tile depth (top) a No. of Lines <br /> Seepage Pit: Inside darer Liquid Depth No.of Seepage Pits <br /> Percent slope of land "i t* Distance from critical slope <br /> WATER SUPPLY: Private ?"Joint ❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <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 Certilj.pd oil Tester- j <br /> NAME Ke , ) 'IN y 1 C f ` p 'A-) I'1 S C.S.T. : and other information <br /> obtained from 1 14 h 1 S u ir. .r k V t? (•caner/builder <br /> Plumber's Signature ,� L • ' '-Z MP/MPRSW# 6 C) .3 / Phone # p66 /ff S 7 <br /> Plumber's Address lrl} 1tit S Y IP93 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not been drilled please indicate. <br /> • <br /> C7L..-/ <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY �h�� BJ <br /> Date of Application as ,' f/ Fees Paid: State J9' County .•/ Date41/i 3 d <br /> �-. /fi� <br /> Permit Rejected (date)Ci ;)3t1 /Jj/ Issuing Agent Name 5O-:, <br /> Inspection Yes No State Valid# Date 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 7/1/78 <br />