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State and County State Permit # <br /> P L B 67 <br /> Permit Application County Permit <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 OFFPROPERTY Mailing Address: <br /> Tort., R Cu,L / <br /> B. LOCATION. A14F / A0'1V /,, Section 3 S, TqO N, R_L'�r r) W Lot# City" <br /> Subdivision Name, nearest road, lake or landmark Blk# <br /> Village <br /> GrE2 EY,TANS/C°irl Township <br /> C. TYPE OF OCCUPANCY: -Commercial "Industrial 'Other (specify) 'Variance <br /> Single family 1/ Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY 75'41 Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete 4--' Poured-in-Place Steel—Fib rglassOther (specify) <br /> New Installation Jl'� Replacement <br /> Lift Pump Tank or Siphon Chamber.Total gallons Prefab concrete_Poured-in-PlaceOther (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate- Total Absorb Area sq.ft. <br /> New___sl�' Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft._�Wi�th_ �pth Tile depth (top) No. of Trenches <br /> Seepage Bed: 7� Length Width�Depth Wt—bb Tile depth (topLe-&-No.of Lines Z— <br /> Seepage Pit: Inside diameter Liquid 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 /> 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 Certified Soil Tester, <br /> NAME �y-,yq„�p Su ND �l C.S.T. Zr/7 5 and other information <br /> obtained from (owner/builder) <br /> Plumber's Signature ^v1P/MPRSW# 9C/ 2� Phone #GJ51-2 ; 7� <br /> Plumber's Address /PT--/— /°�r�/ y' 4 /l/.-,v 6t//sCo Sim <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 /> v <br /> yv <br /> e <br /> . . .. . .. .yrs ..... .. • . . . <br /> Do Not Write in Space Be w -/FOR COUNTY AND STATE <br /> ARTMENT USE ONLY <br /> A ' <br /> Date of cation ees aid: State/0,' County Date <br /> Perm i Issued/ ejecte ate) Issuing Agent Name i <br /> Inspection Yes No 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) <br /> Revised Date 7/1/78 <br />