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i <br /> P L B 6 7 *oPermitPermit <br /> State and County State # <br /> Application County P it # / <br /> for Private Domestic Sewage Systems County _ <br /> 'DENOTES STATE APPROVAL REQUIRED q�7 <br /> Date Approval Received from State if Required State Plan I.D. <br /> A. OWNER OF PROPERTY 'Mailing <br /> / Address: <br /> _�/SSI NG7 vl lr� I4n/rbyr� � <br /> B. LOCATION: N�'/., Section T lfa N, R /_(/- B lot) W Lo _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village _ <br /> Townshipj o /7 <br /> C. TYPE OF OCCUPANCY: Commercial'�y\�.'I._ 'Industrial 'Other (specify) Variance <br /> Single family Duplex Ro. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher _ YES _NO Food Waste Grinder—YES—NO #. of Bathrooms— <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY_ O b Total gallons No, of tanks <br /> 'Holding tank capacity Total gallons No, of tanks <br /> New Installation —A—Addition Replacement Prefab Concrete <br /> 'Poured in Place Steel Other (specify) i <br /> F, EFFLU NT DISPOSAL SYSTEM: Percolation Rate 1) _ 2)�)7 Total Absorb Area 0--sq. ft. <br /> New Addition Replacement - - 'Fill _System .I <br /> seepage Trench: No. Lin /I eel _ Width_ Depth_Tile Depth No. of Trenches_ <br /> Seepage Bed: Lengtfy0 Width Y _Depth 4( r Tile Depth . No. of Lines 3 '/ f <br /> Seepage ,Pit: Inside diameter Liquid Depth Tile Size_7 f <br /> Percent slope of land�'tr�o NF Distance from critical slope <br /> I, the undersigned, do hereby certify that the information 1have 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 C ift Soil Tester, [� <br /> NAME _�V, �(LjT *,a tr, GS.T. # J S and other information <br /> obtained from_�� . -Aa— _ owne ilder). f <br /> Plumber's Signature ✓/\` MP PRSW# -03O 'E Phone # CE6-y1sr] <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H6220, including well). <br /> � I I <br /> rdvo <br /> ' 1 <br /> 1 f <br /> _. f ; - <br /> l f <br /> 1 <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY r^ <br /> Date of Application IC)-IQ- 72 Fees Paid: State 10.QO County� �- dteh <br /> Permit Issued/Rajwq.4-(date) 10- IQ- 77 Issuing Agent Name ttd <br /> Inspection Yes L/No Valid# _^1 Date Recd i <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 6/1/76- <br />