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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 111 <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 /> CA,e4 /fr,aZers J,7AR OF r. �T,,00oiy." <br /> B. LOCATION: B' '/< (� '/<, Section / , T_4/&7 N, R ,�4or) � Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township SGO7T <br /> C. TYPE OF OCCUPANCY: Commercial "Industrial *Other (specify) *Variance <br /> Single family —K Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY 121)0 Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete X 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. EFFLU T DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. <br /> New I Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft. Width Depth Tile depth top) No. of Trenches <br /> Seepage Bed: X_Length--JCL�--WidthAV t Depth 36''le'Tile depth (top 'No. of Lines y <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land_ Z. Distance from critical slope A'O/Iii <br /> WATER SUPPLY: Private IX 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 dee;L X4 Z6"B C.S.T. # .'s:S- 19'.11 and other information <br /> obtained from 0 7 ( caner buil e <br /> Plumber's Signature e!4- X * �,�,� �Af/M ,.,�o (e Phone v.33 37510 <br /> Plumber's Address dP)L, 1 yZ4/64tL. <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 /> IAO _ . <br /> . s m <br /> Do Not Write in Space Bel F R COUNTY AND STATE (WARTMENT USE ONLY <br /> Date o�lication Fes Paid: State County County — Date ! 7 <br /> Perm Issue /Rejecte ( tel Issuing Agent Name <br /> Inspection Yes No State Valid# ate 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) Revised Date 7/1/78 <br />