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PLB V6 State and County State Permit.# <br /> LLL/// L _ Permit Application - County Permit ar _ <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 /> Li]- <br /> B. LOCATION: �,� '/. P %, alion JL, T q( N, RkIL k (or) W Lot# _City , -' <br /> Subdivision Name, nearest/road, lake/or landmark Bilk# Village <br /> Townships/- ' <br /> C. TYPE OF OCCUPANCY: Commercial -Industrial_ 'Other <br /> (specify) 'Variance <br /> Single family Duplex No. of Bedrooms No. of Persons C/ <br /> D. TYPE OF APPLIANCES: Dishwasher YES <br /> _X NO Food Waste Grinder_YES�/NO # of Bathrooms—(_ <br /> Automatic Washer fX� VES NO Other '(specify) <br /> E. SEPTIC TANK CAPACITY Total gallons-- No: of tanks __ <br /> 'Holding tank capacity' Total gallons No. .of tanks. \ <br /> New. .Installation l� Addition Replacemt_ 'X enPrefab- Concrete <br /> 'Poured in Place. Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 11 _ 21 Y 31 Total Absorb Area sd q. ft. <br /> New_ Addition _ Replacement *Fill System - .. <br /> Seepage Trench: No. Lin. Feet_ Width DepthTile Depth No. of Trenches ' <br /> Seepage Bed: Length Width1�Depth LTile Depth 3k .r No. of Lines .� <br /> Seepage Pit: Inside diameter Liquid Depth - Tile Sizey "" <br /> Percent slope of land TIN `- «J 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 EH115prepared <br /> by the Cartijo Sqq��I Tester,, <br /> NAME' 6 CIYh L/v Q .n h/ 5 C:S.T. # _�... _ <br /> --� and other information _ <br /> obtained from /. w yr��--�—(owner/builder). <br /> Plumber's Signature (I ' MP��A PRSW# "3 OJ Phone <br /> Plumber's Address lei- t �s-�2-z _ $ Y J Y.4 ' <br /> PLAN VIEW:. Provide sketch below of system (include direction- of slope and istances in accord with <br /> H6220, including well): <br /> I-1 � 5 �'� � � _ u <br /> -17 <br /> oll:i <br /> - �� <br /> of <br /> I I <br /> i <br /> Do Not Write in .Space Below - FOR 'DEPARTMENT USE ONLY <br /> Date of Application 7-fgE 7 Fees Paid: State�_County —' Date <br /> Permit Issued/Rejected' (date) �-r�..4-7 ] _Issuing Agent Name y1 <br /> Inspection Yes P-�No Valid# �L Daffe 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 Data 6/1/76 <br />