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PState and County State Permit # <br /> Permit Application County Per it # <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,v Mailing Address: <br /> B. LOCATION: '5&1'1 '/<, Section /!!I,, T!�dq N, Rjf [ 1 w! W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township .S!_ p 77— <br /> C. TYPE OF OCCUPANCY: Commercial 'Industrial "Other (specify) 'Variance <br /> Single family A Duplex No. of Bedrooms No. of Persons_ <br /> D. SEPTIC TANK CAPACITY -750 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-PlaceOther (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Areal sq.ft. <br /> New x Replacement Alternate (Specify <br /> Seepage Trench: No.of Linealt. Width Depth Tile depth It )�_No.of Trenches <br /> Seepage Bed:. Length�Width ZR Depth�Tile depth (top) No. of Lines *;21 <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land a '� Distance from critical slope ND1V1dZ_ <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 EH115prepared <br /> by the Certified Soil Tester, / <br /> NAME L/ i ,� ,$'Gt C.S.T. # S$"- 3 and other information <br /> obtained from F '(, lop (owner/builder). <br /> Plumber's SignatureP/MPRSW# 3D 77 Phone # � <br /> Plumber's Address 6 - <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 /> 11(0 .SG.fI e <br /> Vj <br /> 0.4 <br /> 'LA All <br /> p�T <br /> 14reA <br /> o'f R 1 eI <br /> Do Not Write in Spac low - OR COUNTY AND STATE_DEPARTMENT USE ONLY <br /> Date of kation Fees 'd: State��Count D to <br /> Permi Issued/ jected dat 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 />