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P L B 67 State and County State Permit # 113 <br /> Permit Application County Per�nit> Z <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 /> �7; rnS yn's c�j �i'SYing <br /> eNle T. M�tLJ <br /> B. LOCATION: &JV9 % 5.L� '/ , Section 1&, T N, R/JF(or) W Lot# lf 'n� City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township , L4-71A 5S . <br /> SC� t-- �'`�A't2 $'e-(R,t� . 5I'. Cho i x „Tint-�- <br /> C. TYPE OF OCCUPANCY: 'Commercial 'Industrial `Other (specify) Variance <br /> Single family _X Duplex No, of Bedrooms c7Z No. of Persons <br /> D. SEPTIC TANK CAPACITY - '7S7') 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 7t Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete_Poured-in-Place—Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate �- -Total Absorb Area---ZZ'/49 sq.ft. <br /> New )4, Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches <br /> Seepage Bed: �4, Length -02--: Width �A ' Depth-3CLTile depth (top)_ 74 No.of Lines <br /> Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits <br /> Percent slope of land- C��� Distance from critical slope <br /> WATER SUPPLY: Private &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 TesteTr, p�� <br /> NAME _KO 8t! � V - �Y 6C.-Na-Ze—, C.S.T. # !V9'C9L_ and other information <br /> obtained from M 95AIT; (ownerAm 16srl. <br /> Plumber's Signature . d - -r�giq PRSW# ' Phone # �P4t 3S6 7 <br /> Plumber's Address T p <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 /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of A lication 9�� Fees Paid: StateCounty 2 Date �ty <br /> Permit Issued ejecte date) ps il Issuing Agent Name <br /> Inspection Yes No _X State 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) Revised Date 7/1/78 <br />