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State and County State Permit # <br /> 5s <br /> PLB67 7`/ <br /> Permit Application County Permit # _ <br /> for Private Domestic Sewage Systems County Ri,ru <br /> *DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required 6/21/78 State Plan I.D. # 78-02101 <br /> A. OWNER OF PROPERTY Mailing Address: <br /> Eggene R. Neubauer 137 E. Page St. St. Paul, MN 55107 <br /> �'t <br /> B. LOCATION: NW /. NW /<, Section 29 , T 37 N, R18 E-tart W ELot# City_ -- <br /> Subdivision Name, nearest road, lake or landmark Blk# Village -' <br /> Township Trade Lake <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family X Duplex No. of Bedrooms 2 No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES X NO Food Waste Grinder YES X NO # of Bathrooms_I <br /> Automatic Washer YES X NO Other (specify) <br /> E. SEPTIC TANK CAPACITY Total gallons No. of tanks <br /> *Holding tank capacity 2000 Total gallons No. of tanks 1 <br /> New Installation 1 Addition_ Replacement Prefab Concrete <br /> *Poured in Place Steel X Other (specify) <br /> F. EFFtbT4.T DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb sq. ft. <br /> New_ AdajtiReplacement *Fill System <br /> Seepage Trench: No. Li , et Width Di e Depth No. of Trenches <br /> Seepage Bed: Length Width Depth _Tile Depth No. of Lines <br /> Seepage Pit: Inside diametLiquid Depth Tile Size <br /> Percent slope of-tan ` 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 Certified Soil Tester, <br /> NAME Edward R. Schroeder C.S.T. # 55421 and other information <br /> obtained from Eugwe R. Ne auer (owner/builder4. <br /> Plumber's Signature ,y MP/MPRSW# 330 Phone #349-5_364 <br /> Plumber's Address Box W Siren, WI 54872 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> See State Approved plan. <br /> Do Not Write in Space/ Below - FOR DEPARTMENT USE ONLY <br /> / <br /> Date of Application -12-`717 Fees Paid: State /10 ty D <br /> Permit Issued/Rajowed (date) Issuing Agent Name <br /> Inspection Yes_jeo�No Valid# D ?' 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 6/11/76 <br />