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L 6 7State and County State Permit # <br /> r Permit Application County Per # <br /> for Private Domestic Sewage Systems County <br /> 'DENOTES STATE APPROVAL REOUIRED <br /> Date Approval Received from State if Required State . Plan 1,D, # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> N,o /1 AP >< �NYcs/in v:vT �'n �%3 s'I., ,r /•s ro;.v d/ �� 'v'a-e <br /> B. LOCATION: 4/t{. 7a N/= /,, Section /�L, TI-Z_ N, R2.'4_ g (or) W Lot# _City ' <br /> Subdivision Name, nearest road, lakEI or landmark Blk# _ Village <br /> i - Township <br /> C. TYPE OF OCCUPANCY. 'Commercial 'Industrial •Other )spec'fy) Variance <br /> — <br /> single familyE! Duplex No. of Bedrooms Z3 No. of Persons <br /> D. SEPTIC TANK CAPACITY /000 Total gallons Noof tanks / <br /> HOLDING TANK CAPACITY Total gallons No, of tanks <br /> Prefab concrete v/ Pouredin-Place Steel Fiberglass Other (specify) <br /> New Installation Replacement . <br /> Lift Pump Tank or Siphon Chamber t' Total gallons Prefab concrete_Poured-in-Place_Other(Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rare Total Absorb Area L./ 5 sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No of Trenches <br /> Seepage Bed: Length 3/ r Width ' Depth 3C ' Tile depth (top) No.of Ll nes <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land /D �O Distance from critical slope <br /> WATER SUPPLY: Private l!- Joint 0 Community ❑ Municipal,❑ ' <br /> Owners name as listed on EH 115 if other than present owner: <br /> the undersigned, do hereby certify that the inlormauon I have reported is in accord with Section H62.20, - <br /> Wlsconsin Administrative Code, and that I have seed the effluent disposal system from the EH 115 prepared <br /> by the Certified Soil Tester, , <br /> NAME /+ h /)/,L CSL # and other information <br /> obtained from Aip ye (owner/builder). <br /> Plumber's Signature (<) Baca-I e�- MP/MPRSW# r'1 4' `�- Phone # (35 '' �L/r7- <br /> :1 Plumber's Address 4/-t as'— —L S 9 jtof <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 /> 1 rE property. If well has not been drilled please indicate. <br /> r P.. as J� iY.'T Tn j 5 , rov <br /> Lle. Ae <br /> ,v I <br /> z=( <br /> T fptn z7n ] <br /> it <br /> I <br /> P <br /> Do Not Write in Space B ow OR COUNTY AND ST TEDEPARTMENT USE ONLY re ���JJ <br /> Date of Lication Q F s Paid: Star./,/' _ CMy,_ �Da C� <br /> r Permit Issued.Relect ate) Issuing Agent Name (�// - /// //,L�� <br /> /�6 <br /> Inspection Ves !/ No _ State Valid# Date Ree'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 Data 7/1/78 <br />