Laserfiche WebLink
p State and County State Permit # <br /> Permit Application County Perini <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 /> (5 L R av ZE C tl � �TR�4 <br /> B. LOCATION: /< l— ,, Section , T /�N, R�E (or) W Lot# �_City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township MCI <br /> C. TYPE OF OCCUPANCY: 'Commercial `Industrial `Other (specify) 'Variance <br /> Single family —X­ Duplex No. of Bedrooms 42. No. of Persons_ <br /> D. SEPTIC TANK CAPACITY / f l Total gallons No- of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete._ Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation �x Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Pllaacce�� Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate — Total Absorb Area /�z sq. ft. <br /> New _Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No.of Trenches <br /> Seepage Bed:_ 2S _Length a y�Width Depth -, r r Tile depth (top)a No. of Lines——� <br /> Seepage Pit: Inside diametr Liquid Depth No.of Seepage Pits <br /> Percent slope of land_ / e� U-" Distance from critical slope <br /> WATER SUPPLY: Private PlIcint ❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <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 EH115prepared <br /> by the Ce r ted- Soil Te ter, <br /> NAME (� e C C.S.T. # and other information <br /> obtained from 1 cVC4 (owner uilder). q� f� <br /> Plumber's Signature MP/MPR C S Phone # 0 � 7/f 7 <br /> Plumber's Address r <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not been drilled please indicate. <br /> r <br /> a� <br /> 1gX <br /> /br <br /> /aE <br /> yo <br /> i�wtll rh5 <br /> Do Not Write in Space Bel 0 It CIO <br /> COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Ap lication Fes P id: State County to <br /> Perini ssu /Rejected tel Issuing Agent Name <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, WI 53701 <br /> 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 <br />