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I p� sI /N� 7t State and County State Permit # �� <br /> ■ L �^ / z E P>.mit Application County Permit <br /> NV — for Private Domestic Sewage Systems County <br /> i <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. at <br /> A. OWNER OF PROPERTY Mailing Address'. <br /> s 4 /6y1 w �sr cu7t5 'Z . 19--Iff <br /> B. LOCATION: t I % Section T N, R-® (or) W Lot= _City <br /> Subdivision Name, nearest road, lake or landmark BIk= Village <br /> Co 17 l/0 rr l,0 /� Township P vP <br /> C. TYPE OF OCCUPANCY: 'Commercial 'Industrial 'Other (specify) 'Variance <br /> Single )amity Duplex No. of Bedrooms No. of Persons_ <br /> D. SEPTIC TANK CAPACITY ; X(S /aTotal gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons Noof 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 SVSTE percolation RateTotal Absorb Areasq. if <br /> New Replacement Alternate (Specify) <br /> Seepage Trench:X No.of Lineal Ft. p�Width -Delpth_Tile depth 7,,--No.of Tre ch` es <br /> Seepage Bed: Leng[hFiWidthJ-aDep[hTile depth (top No.of Line <br /> Seepage Pit: Inside dto�erT Liquid Depth No.of Seepage Pits <br /> Percent slope of and to o t...J Distance from critical slope <br /> WATER SUPPLY: Private u Joint❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <br /> I, the undersigned, do hereby certify that the informelion 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 lied Soil aTest <br /> NAME V r (� O [ Lip C S.T. a Y3 7 and other information <br /> obtained from 4 t7, f, I p si (owner/builder) <br /> Plumber's SignatureMP/MPRSW* t / Phone cas� <br /> Plumber's Address- •ry•F 2 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well Inca <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors is <br /> property. If well has not been drilled please indicate. \. <br /> { <br /> I <br /> t <br /> 1 <br /> I <br /> - <br /> �t <br /> _ _ <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application 9a6! 71) /9P/ Fees Paid: . State /Y County t Date <br /> 5sue3/ ti/'9P/ al <br /> Permit 9ejected (datel j j i;7/ Issuing Agent Name T(/ � ,Y^1 <br /> Inspection Yes No % State Valid* Date) Recd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, W1J53701� <br /> 2. state (pink ropy) 4. lumber _ <br /> P (canary copy) <br /> -- Revised Date 7/1/78y <br />