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P L B 67 State and County State Permit # <br /> Permit Application County Per <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 (� r Mailing Address: ,L/ <br /> 0 'rr- 1 r/ T r -e f Y S,J, ' � /� a n 1 � 'TC,; v /�C b / i qte <br /> B. LOCATION: y -J I/ %<, Secti , T ON, R fLL42 (or) W Lot# City z <br /> Subdivision Name, nearest road, lake or landmark Blk# Village / <br /> Yr ,`L- Ho uj 4 (1 Irk Township <br /> C. TYPE OF OCCUPANCY: 'C mmercial `Industrial 'Other (specify) 'Variance <br /> Single family _Y Duplex No. of Bedrooms No. of Persons —?— <br /> D. <br /> ersonsD. SEPTIC TANK CAPACITY S 0 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. EFFLUENT DISPOSAL SYSTEM: Percolation Rate , Total Absorb Area sq. ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top1_No. of Trenches <br /> Seepage Bed: x Length 019 WidtW�r Depths—Tile depth (top) S rr No. of Lines <br /> Seepage Pit: Inside/d'am �—eter Liquid Depth No. of Seepage Pits <br /> Percent slope of land L � Distance from critical slope <br /> WATER SUPPLY: Private oint ❑ 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 Certi�i 0 SPii Tester, ! _ (l , <br /> NAME I ) 6 Willie r r c !'� Vol p J7 I Y1 S C.S.T. # 2 and other information <br /> obtained from Q^ri­k4 (I 2 TS 9 (owne / ilder). <br /> Plumber's Signature ,1 P/MPRSW# Phone # <br /> Plumber's Address-- rrS</Qy2 <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 /> �40 I \ <br /> F X7- <br /> 7o <br /> Not Write in Space o O OUNTY AND STATE DMARTMENT USE ONLY <br /> Date of A lication e s id: State��County ate <br /> Permit ssued/ ejecte da 1 Issuing Agent Name <br /> Inspection Yes No State Valid# ate Rei 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) Revised Date 7/1/78 <br />