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Plb 67 State and County State Permit # <br /> " Permit Application County Per 't # <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 /> I~IZ4!AAC5 RT- o,c��� awjwTs13 v�rzc c cQ.c.s.v <br /> B. LOCATION: NJ '/a fO ''%, Section 0, T N, R / (or) W Lot# -City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township P,iul*•S <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family --7)!(— Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwas er YES NO Food Waste GrinderYES O # of Bathrooms <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY /GAO U Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation l/ Addition Replacement_ Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUE DISPOSAL SYSTEM: PercolatioyRate 1) 2) 3 3) Total Absorb Area 'y/G) sq. ft. <br /> New Addition Replacement � *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> i ,. a <br /> Seepage Bed: Length 7! �(i Width /�-O Depth 4-46" Tile Depth -G No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size C/'� <br /> Percent slope of land 7+— � 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 EH-115 prepared <br /> by the Certifi Soil Tester, <br /> NAME C/f7 ? �G/�St/c- C.S.T. # y1�� and other information <br /> obtained from eaf! (owner/builder). <br /> Plumber's Signature fir- MP/MPRSW# may? / Phone <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> � 18Lo"1C3N=4" <br /> ( 96-a" <br /> PIS p <br /> � j o scat vc f't1 G � E <br /> rk <br /> IT <br /> N" OlFji- Rpa To <br /> W y <br /> /4&6'-c ' <br /> L i rr s7 www /aLo'• pR�„ f►a�srr <br /> pal i P Psn-�y & <br /> Do Not Write in Space Below - FOR DEPARTMENTUPE <br /> 7,Pt <br /> Date of Application Z- Fees Paid: State County Dat <br /> Permit Issued/RojectLd (date) 7 -7 Issuing Agent Name <br /> Inspection YesJ"No Valid# i Dat /)Rec'd <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) <br /> Revised Date 3/1/75 <br />