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p State and County State Permit # /5W3 <br /> Permit Application County Permit # 96-76 <br /> ® for Private Domestic Sewage Systems County B"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 /> L E,�V&6&'aV Er>�/ n/ Z ti���a��, cvi, s-vi?3c� <br /> B. LOCATION: A, L '/4 A I '/4, Section ; , T N, R��t '(6r) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township SCC1S,5;- <br /> ,7-,47 i<,g y5 �S 5 'I'1 /moi' F1,_c, t:bccZ- <br /> C. TYPE OF OCCUPANCY: Commercial `Industrial 'Other (specify) Variance <br /> Single family Duplex No. of Bedrooms Q No. of Persons <br /> D. SEPTIC TANK CAPACITY /2 0( Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in-Place Steel_Fiberglass Other (specify) <br /> New Installation Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other(Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. <br /> New X Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft.—Width—Depth—Tile depth (top)_No.of Trenches <br /> Seepage Bed:X_Length___Vj6_1Width /9 Depth 3L Tile depth (top) -3r� No.of Lines 3 <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land A2-A T Distance from critical slope <br /> WATER SUPPLY: Private KJoint❑ 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 Certified Soil Tester, <br /> NAME RO/J A-j. /���f 4-1 7— C.S.T. and other information <br /> obtained from IL f A --7,_ (owner/ uilder <br /> Plumber's Signature MP/MPRSW# "r7Z Phone # 24 3 jC»7 <br /> Plumber's Address 1� '514 k ? G <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 /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application /9,7/ Fees Paid: State /91 County Date � /O, <br /> Permit Gued ejected (date) 11P Issuing Agent Name ae s� <br /> Inspection Yes No� State Valid# Date Recd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOA( 309, MADISON, WI 53701 <br /> 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 <br />