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P � State and County State Permit at <br /> - Permit Application County Permit ss ir /Zj / <br /> for Pfivate Domestic Sewage Systems County Burnett <br /> DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan 11). _ <br /> A. OWNER OF PROPERTY Mailing Address: <br /> Fred Seifert Webster, WI 54893 I <br /> B. LOCATION: /. E /., Section 1 <br /> SW '� �, TUN. R1§- E-{wF W Lot>= City � <br /> Subdivision Name, nearest road, lake of landmark BlkB Village <br /> Gov. Lot U 3 Township Nestor! <br /> C. TYPE OF OCCUPANCY: 'Commercial 'Industrial 'Other (specify) 'Variance <br /> Single family x Duplex No, of Bedrooms - 3 No. of Persons <br /> 0. SEPTIC TANK CAPACITY Total gallons No. of tanks 1 exsisting <br /> HOLDING TANK CAPACITY Total gallons Noof tanks <br /> Prefab concrete Poured-imPlace Steel Fiberglass Ober Ispecifyl <br /> New Installation Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concretePoured-in-Place_Other(Specify)_ <br /> E. EFFLUENT DISPOSAL SYSTEM. Percolation Rate 33-3Total Absorb Area SIS sq. ft. <br /> New Replacement x Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth—Tile depth (total No.of Trenches_ <br /> Seepage Bed: x Length 35' Width 18' Depth 42" Tile depth (top) 30n No. of Lines 3 <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land Level Distance from critical slope <br /> WATER SUPPLY: Private CN Joint ❑ Community D 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 /> WisconsinAdministrative Code, and that I have sized the effluent disposal system from the EH 115 prepared <br /> C <br /> by the gift dd SScTe <br /> star, <br /> tar, 55 421 <br /> NAME C.S.T. x and other information <br /> obtained from _ owner (owner/builder). <br /> Plumber's Signature .o ^ rylp/MPHSWF 330 Phone = 349 _51§A3 or <br /> Plumber's Address Siren, WI 54872 4YS c.>s <br /> PLAN VIEW: <br /> Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included oa the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not beendrilledplease indicate. <br /> It <br /> 3 ` <br /> ram /PPI 3 ��� "WEu <br /> T- <br /> 1 <br /> I <br /> L <br /> / eetbxi/x C(� F, /�?L milt /n/-I <br /> MinJ' `O' <br /> Do Not Write in Space B ow qF R COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of ¢anon / Fee Paid: State County Date <br /> Permi Issue Relected bate) Issuing Agent Name _ /1) ��p0 <br /> Inspection Yes No _ _ State Valid# 7L/Cj?rG - 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) �Reviled Date 7/1/71 <br />