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PLB67 State and County • State Permit # <br /> Permit Application County Pe mit # <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 /> L v 4 NE 3 a t4ti-,%0N P kTS`KC)P_C . <br /> B. LOCATION: % S� Y4, Section �, T N, R {.� W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> TownshipWoub j r&Z <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family X Duplex No. of Bedrooms No. of Persons <br /> a <br /> D. TYPE OF APPLIANCES: Dishwasher J,V_ YES NO Food Waste Grinder YES ' NO # of Bathrooms_ 7�7 <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY -Qb Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation A'O* Addition_ Replacement_ Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) a 2) 3) Total Absorb Area sq. ft. <br /> NewX Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: LengthWidth Depth�+Tile Depth No. of Lines ?_ / <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size T <br /> Percent slope of land � l�� 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 C tified Soil Tester, <br /> NAME J N ay B V j, C.S.T. #_5Z_ 11-72—and other information <br /> obtained from ' ' 0 /VSO owne builder). l� <br /> Plumber's Signature MP/MPRSW# T Phone #W ra—�?60r <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). ` <br /> /Oath <br /> G,r4 <br /> a <br /> 0 <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application � - �S -7 7 Fees Paid: State 1 j.o C) Cou Da e <br /> Permit Issued/ /d (date) - _Issuing Agent Name <br /> Inspection Yes y 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 6/1/76 <br />