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PIb 67 - State and County State Permit #�L <br /> PermitesticS wag County Permjt 3t _— ,I <br /> for Private Domestic Sewage Systems County —4l/�1,�./°1.'(. <br /> q 'DENOTES STATE APPROVAL REOUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> I <br /> A. OWNER OF PROPERTY - Mailing Address: <br /> 1e , p y e �DS e� 6 90 A20 nr� <br /> B. LOCATION: IZ%�Section , j, T_ 9N, R_(j'g (or) W Lot# _City <br /> Subdivision Name, nearest road/, lake or landmark Blk# Village ` <br /> .SQ M U �..G/t p TownshipgS'.(��'r7lV• <br /> C. - TYPE OF OCCUPANCY: 'Commercial 'Indust vial 'Other (specify) 'Variance <br /> Single family p Duplex No. of Bedrooms No. of Persons__ <br /> D. TYPE OF APPLIANCES: Dishes sher _ VES x NO Food Waste Grinder_YES_KNO # of Bathrooms <br /> Automatic Washer _YES NO Other (specify) <br /> E F SEPTIC TANK CAPACITY ! S 0 Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation x Addition Replacement Prefab Concrete f <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)_31 Total Absorb Area d sq. ft. <br /> New_X_ Addition _ Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width DepthTile Depth No. of Trenches_ <br /> Seepage Bed: Length a o,-Width Depth 3y,• Tile Depth a y •, No. of Lines 41- yv <br /> Seepage Pit: Inside diameter u id Depth Tile Size <br /> Percent slope of land_- Q yam, 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 Certif' d oil Tester y <br /> NAME � p_f(_ � ry I GS.T. y / and other" information l <br /> obtained from L'. 11 e W d r (own tmidiri 'p 1 <br /> Plumber's Signature /Pr MP/MPRSW# 0 3 0 T S Phone # 411J' 7 ' I <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord ,with <br /> H62.20, including well). l <br /> ( <br /> it <br /> I <br /> I Ir <br /> i Do Not Write in S we Below - FOR DEPARTMENT USE ONLY <br /> Date of Application ]�L Fees Paid State )— County [e <br /> _ Permit Issued/RejwecL (date) - --�---Issuing Agent Name <br /> ' Inspection Vesi Valitl# ate RePtl <br /> j. 1.- county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701, <br /> I 2, state (pink copy) 4. plumber (canary copy) - Revised Data 3/1/75 <br />