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PLB 6 7 s9� <br /> State and County State Permit # <br /> Permit Application County Permit # 966,7 <br /> for Private Domestic Sewage Systems County 14511 <br /> `DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required 7 — / State Plan I.D. <br /> A. OWNER OF PROPER Mailing Address: <br /> R 4 r 1`e S O SS 0 0 ct i- F / e q Ors R,- ti -Pd <br /> B. LOCATION- /4 /4, Section T Y6 N. R / ) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village / <br /> X Township Q E/E4 fn� ll� w Ce �.� d <br /> C. TYPE OF OCCUPANCY: Com ercial "Industrial Other (specify) *Variance <br /> Single family Ll--�Duplex No. of Bedrooms . No. of Persons <br /> D. SEPTIC TANK CAPACITY Total gallons No. of tanks <br /> HOLDING TANK CAPACITY d @ Total gallons No. of tanks �-- <br /> Prefab concrete— 'Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation l� Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area 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: Length Width Depth—Ti le depth (top) No.of Lines <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land Distance from critical slope <br /> WATER SUPPLY: Private 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 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 Cer d St Tester, r <br /> NAME Q �r P /c /VC y� 7 and other information <br /> obtained from 4 C I O wn uilder). p '` <br /> Plumber's Signature �(MPRSW# C S 7 Phone # �� Y LEI <br /> Plumber's Address ^� Y <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 E <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of A h 3ation e?�! 41P Fees Paid: State 74/ County / Date 7 <br /> Permit ssue Rejected (date) g2, 7 g0 Issuing Agent Name <br /> Inspection Yes_I_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 />