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PLB67 and _ <br /> State and County Stare Permit #_ ccrcccTTT <br /> Pe rmitestic Sewage <br /> County Pe [ <br /> for Private Domestic Sewage Systems County <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State. it Required State Plan ID. At <br /> A. OWNER OF PROPERTY -7-• Mailing Address: S--J q2 j <br /> B. LOCATION: .5W y. IV"/'/., Section - '7 T YON, R/6 6 (or) W Lot# _City <br /> Subdivision' Name, <br /> nearest road, lake or landmark Blk# Village / <br /> TownshipG Q 12-4r/Q <br /> C. TYPE OF OCCUPANCY: 'Commercial • *Industrial 'Other (specify) 'Variance <br /> Single family Y Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: DishVvpsher YES NO Food Waste Grinder—YES YNO # of Bathrooms_ <br /> Automatic Washer_YES X NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7,S- 0 Total gallons No. of tanks <br /> 'Holding tank capacityy� Total gallons No. of tanks v <br /> New Installation _`//KAddition Replacement Prefab Concrete K- <br /> .*Poured in Place Steel Other (specify) - <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) -, 21 <br /> .Ja 31 Total Absorb Area sq. ft <br /> New n Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Fee[ Width_ Depth Tile Depth . No. of Trenches_ <br /> Seepage Bed: Length o0, 0' Width /-I ' Depth � Tile Depth �' `( No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Sizey <br /> Percent slope of land—/—! 5 Ca_1 Distance from critical slope �1 <br /> I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, j <br /> Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared <br /> by the Ce fled Soil Tester, I <br /> NAME y1 c!­e r . i. /'U ('4 !;. O.S.T. # �� and other information <br /> obtained from /� - 11Jrc �_(ownedbuilder). <br /> Plumber's Signature �u K.�c M'4i,i '" MP/�1p�SW# U� 03 y Phone # <br /> Plumber's Addressy '� L+-t-^'*-�� S 4 1 S <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> - <br /> 70 <br /> SIS IS <br /> l V- <br /> {I <br /> E <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application 77 Fees Paid: S[ateCoun[y— ate aT� <br /> Permit Issued/Rejaated (date) ���-77 Issuing Agent Name L 1� Q <br /> Inspection Yes_ye�'No Valid# ate Ree'tl <br /> 1. county (white copy) _ 3. owner (green -copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 i <br /> 2. state (pink copy) 4. plumber (canary copy) <br /> - -- — Revised Date 6/1/76 <br />