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*DENOTES STATE APPROVAL REQUIRED Stale Plan <br /> Date A poval�Ryived from State if Required '--�_�-ow 1 r k e Mailing Address: <br /> A. OWNER OF PROPERTY <br /> '.� q ,� -C LI ~(' 1' rl y �l .J Q n N - IE (or) W Lot# _City ------' <br /> * y` e� , Section �-� Village <br /> B, LOCATION: <br /> Subdivision Name, nearest road, llake or landmark $!k# Township <br /> 0 •Other (speorfyl *Variance <br /> Industrial _ <br /> TYPE OF OCCUPANCY: Commercial No, of fpons <br /> Single family _ Duplex No. of Bedrooms,__, ._._. -- <br /> �NO Food Waste GrinWer___ YES NO # of B " a <br /> p. TYPE OF APPLIANCES: Dishwasher <br /> YES , . <br /> Automatic Washer YES NO Other (specify) <br /> Y <br /> 0 0 Total <br /> E. SEPTIC TANK CAPACITY gallons No. of ,tanks <br /> Total gallons No. of. tanks.-___.__—___ <br /> *Holding tank capacity Prefab Concrete_ <br /> New Installation <br /> Addition_�.____--.-Replacement __----- <br /> Steel_ ___ Other (specifyl ----- <br /> *Poured in Place 3) Total Absorb Area ..--sq. ft' <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) <br /> Replacement___ *Fill System _�-- No. of Trenches <br /> New_k Addition Death Tile Depth ___.___-_—_ -- — <br /> Width —_ No. of Lines _. ..__. <br /> Seepage Trench: No. Lin. Feet Depth '� Tile Depth__a <br /> Seepage Bed: Length Width �_ Tile Size <br /> Se Liquid Depth------ <br /> epege Pit: Inside diameterDistance from critical slope C' — <br /> Percent slope ofis <br /> landrax- <br /> i ned do hereby certify that the information I have reported <br /> systemaccord f om heh Sect <br /> 1, the p eIpared <br /> Wisconsinn Administrative <br /> g d ,ministrative Code, and that I have sized the effluent P <br /> by the Ce 'fied Soil ,Tester, f C S # -- _ v and other information <br /> NAME 0 r'r wnerl uilder). -� p <br /> q � l�1 Phone #_ --- — -- <br /> obtained from MP/MPRSW# _ <br /> Plumber's Signature p _--- <br /> Plumber's Address --- <br /> PLAN VIEW: Provide sketch below of system (Include direction of slope and all distances in accord with <br /> H132.20, including well). <br /> -�J <br /> , <br /> , <br /> I � _ <br /> i <br /> r , - <br /> , <br /> - <br /> i f <br /> , <br /> , <br /> Do Not Write in Space B low FOR DEPARTMENT USE ONLY County ate " <br /> -7 Fees P id: State= --- <br /> Date of Application Issuing Agent Name <br /> (date) - ate Rec'd <br /> Permit Issued/A�e�t9d Valid# <br /> Inspection Yes_ � 3. owner (green copy) <br /> No DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI 537( <br /> r <br /> 1. county (white copy) 4. plumber (canary copy) Revised Date 6/111 <br /> 2. state (pink copy) <br /> k - <br />