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. , ..., ,. <br /> L~ State and County r State Permit # <br /> F 1 <br /> Permit Application County Permit <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 PROPERTY Mailing Address: <br /> Z1K JoDy SAuGsTAb 'uloC goi � cPcti'/ c <br /> B. LOCATION: /4 /4, Section 3-S- T`'/ N, R i(p E (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Loy.is Y ree/N6 OAT S R r Township e rty <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family k Duplex No. of Bedrooms 3 No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher "S'ES NO Food Waste Grinder YES A 170 # of Bathrooms_' <br /> Automatic Washer 9YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY VZ—CrO Total gallons No. of tanks I <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation '4 Addition Replacement Prefab Concrete <br /> *Poured in Place Steel Other (specify) / <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) *3 2) 3 3) Total Absorb Area T 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 5-Z.-Width /2.- Depth—VT,— Tile Depth 2? No. of Lines `2"--- <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size , <br /> Percent slope of land 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 Certified Soil Tester, , <br /> NAME EDtAi A-et, ' C ry (1460 C.S.T. # 55.th, i and other information <br /> obtained from (owner/builder�),.ne� �/ <br /> Plumber's Signature itt.P.--7-1 t,� MP/MPRSW# /�'IT S7?1 Phone #g*— Q <br /> Plumber's Address ems• <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, Mee including well). �.. _p t1E <br /> ` i WM CLAM C <br /> .210 > <br /> obi P <br /> V $70 aptI) <br /> N --*-- ',(;lcrE0 <br /> Ste" % <br /> .#.0, \ <br /> iV <br /> NIP ft - — <br /> Do Not Write in Space Below - FOR DEPA EN ySE ONLY <br /> Date of Application 3 7 Fees Paid: State/d County ate <br /> Permit Issuedfdie}eeted (date) s=3/73. Issuing Agent Name XteInspection Yes J/ No Valid# , 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 />