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Single family , Duplex No. of Bedrooms Ak No. of Persons <br /> D. SEPTIC TANK CAPACITY 7,P O Total gallons No. of tanks !' <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation Replacement >,— <br /> Lift <br /> CLift Pump Tank or Siphon Chamber 00 Total gallons Prefab concrete XPoured-in-Place—Other (Specify) <br /> E. EFFLUENT DISPOSAL SYST Percolation Rate Total Absorb Area sq. ft. <br /> New—Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineel Ft.—Width—Depth—Tile- depth (top No.of Trenches <br /> Seepage Bed:_X _Length oly Width IP -f6 Tile depth '(top " No. of Lines <br /> Seepage Pit: Inside diiamm er Liquid Depth No.of Seepage Pits <br /> Percent slope of land.. A W Distance from critical lope <br /> WATER SUPPLY: PrivateJoint❑ Community ❑ Municipal ❑ <br /> Jwners 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 E14-115 prepared i <br /> by the Certified SoilTes ever, I <br /> NAME hr c..,,l A 0 X, k I H C C.S.T. # and other information <br /> obtained from' .Q Y ( wilder). P� <br /> Plumber's Signature MP/MPR 3 0 f p Phone I-//S 7 <br /> Plumber's Rddress <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 /> 1 <br /> , f I <br /> i <br /> o I <br /> _ I <br /> 'rot <br /> # I <br /> I <br /> i <br /> f <br /> I . Y <br /> ! <br /> I � <br /> Vill <br /> i <br /> , I <br /> i <br /> Not Write in Spacq% elo - FOR COUNTY AND STATE_DEPARTMENT USE ONLY <br /> rte of AoRlication. 944 Fes Paid: State �1J. County Date !� <br />:rmi Issue Rejecte (dat 1'r 3. Issuing Agent Name <br /> speciion Yes No t,^e +" State Valid# Date Recd <br /> IN <br /> county (white copy) 3. owner (green copy) DIVISION OF HCALTH, P.O. BOX 3)9, MADISON, WI 53701 c <br /> state (pink copy) `` 't' w4. plumber (canary copy) <br /> Revised Date 1/78 <br />