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PLB 6 7 State and County State Permit # 000 <br /> 705foPermit Application County Permit # 774,5- <br /> for <br /> r 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 / �f p q Mailing Address: - �• Yy� <br /> /f`^ 4 v /!( it i P -P C !l / y / G' / /—7 7�r X v A] <br /> B. LOC ION: VW % YW 1/a, Section LO T C N, R_Z_rIJ (or) W Lot# S,2 City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> ?0Y - Township J 4C S,, <br /> C. TYPE OF OCCUPANCY: "Commercial "Industrial *Other (specify) "Variance <br /> Single family x Duplex No. of Bedrooms No. of Persons_ <br /> D• SEPTIC TANK CAPACITY 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-Place Other (Specify) <br /> E. EFFLUENJ DISPOSAL SYSTEM: Percolation Rate - Total Absorb Area sq.ft. <br /> New—Replacement—Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth—Ti le depth (top) No.of Trenches <br /> Seepage Bed: Length Width / 0 Depth 36 Tile depth (top) No. of Lines -� <br /> Seepage Pit: Insid ,c peter . iquid 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 /> 1, 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 fied oil .Test r, '! <br /> NAME ( iC U t S C.S.T. # 7 �7 and other information <br /> obtained from 4 t rC (owner/builder). ® `� <br /> Plumber's Signature /MPRSW# e3 Uy Phone # R6 —71E7 <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 /> lop .. <br /> tib <br /> w 7 <br /> 1 r C <br /> �tl " <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY '" q <br /> Date of Application — .Z-5O Fees Paid: State' <br /> ��County Date <br /> Permit Issued/Rejected (date) Issuing Agent Name <br /> Inspection Yes No f� 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 />