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Plb 67 ie~,-'--Ili State and County State Permit # <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 /> 1e0 beri 5c. cl i 2 a .7 oZ Stode. h 'I' /-* Cut fSC, <br /> B. LOCATION: AAA)'/4 I1 E %, Section , T S/0 N, R / ki (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> d d/jra, SG !,) /'. Township ...rCt p <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family Y Duplex No. of Bedroomy C kt.) It) "t_ No. of Persons f <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms <br /> Automatic Washer X YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 174-N .D Total gallons No. of tanks / <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition Replacement Prefab Concrete k <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) o2 2) o?,t<S3) 4.0.1T'otal Absorb Area /6 t' sq. ft. <br /> New X Addition Replacement *Fill System <br /> Seepage Trench: No. Li . Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length / 7 Width /a ' Depth 3 6 t� Tile Depth AY r No. of Lines a <br /> ei "i <br /> Seepage Pit: Inside diamet Liquid Depth Tile Size <br /> Percent slope of land o Distance from critical slope 4.--1" <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 CertiA51 Spit Tester, <br /> NAME t cZ r r i C J r l Qe /h 1 C.S.T. # 93 7 and other information <br /> obtained from C 4 w Q /jçA f (owner/builder). p� /� 1� <br /> Plumber's Signature MP/MPRSW# © cZ 9 Phone # d�D 7 J`.f7 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> - ! ' ( S <br /> x Sf �wk,. S 4 .1' `�` <br /> �Or' /TY / <br /> fidyencf/ G ht 4 4 ilry <br /> /Xv ' 7 ( I 90 Ti r, dd /d.X 3J- <br /> et <br /> 7:::(ZreS <br /> r 40. <br /> - - --7 w, \ <br /> -1 is / <br /> , . <br /> ......-- <br /> ,, <br /> ,...... ,, , , <br /> , s <br /> o j� / <br /> AN <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State County Date <br /> Permit Issued/Rejected (date) _ Issuing Agent Name <br /> Inspection Yes No 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 3/1/75 <br />