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! Plb 67 .- State and County State Permit # J 7 <br /> L Permit Application County Perrot # _6 <br /> for Private Domestic Sewage Systems County — LCC4° - <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 /> -l9 � dr` ,.., h 3/ 4S /1drdcr lgrr ,vc %-/01 < 'J" <br /> B. LOC ION: W''/. W '/., Section d 'r , T3_N, R1,S_ (or) W Lot# —City - <br /> Subdivision Name, . nearest road, lake or landmark Blk# Village <br /> OTownship Fa 6Lr � <br /> —�r41 f e r t .� <br /> C. TYPE OF NCY OCCUPACommercial 'Intlustriali 'Other (specify) 'Variance <br /> Single family x_ Duplex No, of Bedrooms No. of Persons_ <br /> D. TYPE' OF APPLIANCES: Dishwasher VES NO Food Waste _Grinder YES-_�C-NO _ # of Bathrooms <br /> Automatic Washer - VES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY ' "7-T0 Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation X - Addition Replacement Prefab Concrete x <br /> 'Poured in Place Steel Other .(specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate .1) _ 2) j 31 Total Absorb Area y s q. ft, <br /> NewX Addition Replacement 'Fill System i <br /> Seepage Trench: No. Lin. Feet .. Width Depth Tile Depth No. of Trenches_- 1 <br /> Seepage Bed: Length AV Width =Depth ' Tile Depth ..� �r No. of Lines 3 xr <br /> Seepage 'Pit: Inside diameter Liquid Depth - Tile Size <br /> Percent slope of land - Distance from critical slope 3 d <br /> I, the undersigned, do hereby certify that the information I have reported is in accord with Section H6220, <br /> Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared <br /> by the Cartifi� Soil Tester - <br /> NAME _>� S C 6 r o (•Jp r C.S.T. # $-S V d I, and other information <br /> obtained from o c (owner/builder). n <br /> Plumber's Signature r MP/MPRSW# U -� `j .7i Phone # /oG— <br /> _ I <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with- <br /> H62.20, including- well). - <br /> - <br /> ' <br /> r <br /> _ I f <br /> -;�-, <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY <br /> Date of Application - - ' Fees Paid: State �Q County <br /> Permit Issued/Rejected (date) -� — Issuing Agent -Name <br /> Inspection Yes !�o_ - Valid# _Date Rer'd - .I <br /> 1. county (white copy) 3. owner (weed'copy) -DIVISION OF HEALTH, P.O..BOX a. 309, MADISON, WI 53701 <br /> 2. state (pink copy) 4, plumber (canary copy)-­ - I <br /> Revised Date 3/1/75 <br />