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P)b 67 State'antl County State Permit # <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 OF PROPERTY Mailing Address: <br /> B. LOCATION: _ :� %. 5"y_'/., Section 'ZLL, T40 N. R j iII_ Ems) W Lot# —City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township <br /> C. TYPE OF OCCUPANCY: "Commercial 'Industrial 'Other (specify) 'Variance <br /> Single family X Duplex No. of Bedrooms_3 No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher -- - <br /> ishwasher _ YES NO Food Waste Grinder_YES . NO # of Bathrooms— <br /> Automatic Washer-21/—YESNO Other (specify) <br /> E SEPTIC TANK CAPACITY 475=Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation -II Addition Replacement Prefab Concrete <br /> 'Poured in Place Steel >r— Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ­�__ 2) Z-3) _Total Absorb Area iZ S 5' sq. ft. <br /> New ?( Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth_Tile Depth No. of Trenches <br /> Seepage Bed: Length :2-IL-Width iC Depth jC't Tile Depth 24 No. of Lines <br /> z- <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size °( <br /> Percent slope o1 land 0 Distance from critical slope�c5n " <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 eto'" F �r...5¢. (L C.S.T. # re� '"T�-_and other information <br /> obtained from 4 l cN hi,,, Iaadldrd. <br /> Plumber's Signature f— �. Mp/Mppr�y# itY�LZ Phone #;���--- .jC7L <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> I <br /> !Wes,.. Stipp <br /> l0 ±r <br /> LLD <br /> 1 I - <br /> - - �- <br /> ! ;— <br /> I m` I ! I I <br /> 1 I <br /> -� I-I <br /> - <br /> LI <br /> ' <br /> 9 z r-O: <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State County Date <br /> Permit Issued/Rejected (date) Issuing Agent Name <br /> Inspection Yes No 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 3/1/75 <br />