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PLB67 State and Cohnty , State Permit # <br /> Z+ Permit Application County Per 't # <br /> for Private Domestic Sewage Systems County Yfa <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 /> XX L11� 644ff7 <br /> B. LOCATION: / AAV '/a, Section �, T_Y46N, R�,� (or) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village �"� <br /> Township u7oo +rte <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family __K, Duplex No. of Bedrooms f No. of Persons_._ <br /> D. TYPE OF APPLIANCES: Dishwasher YES KNO Food Waste Grinder_YESANO # of Bathrooms-1 <br /> Automatic Washer YES_XNO Other (specify) _ <br /> E. SEPTIC TANK CAPACITY '76'r Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation 1141 Addition_ Replacement Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) '3 3) _Total Absorb Area- caqosq. ft. <br /> NewY!\ Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile D pth No. of Trenches <br /> Seepage Bed: Length_910 Width Depth Tile Depth No. of Lines C2�, <br /> Seepage Pit: Inside diameter- Liquid Depth Tile Size 4/- <br /> Percent slope of land Distance from critical slope _ <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 Ce ' 'ad Soil Testerr �')/) �) + <br /> NAME _ V7 I Qt/'��( , C.S.T. # Z""7 [ -N and other information <br /> obtained from (ownerAliaw di►). <br /> Plumber's Signature 4WMPRSW# �O 7;L- Phone #Z� 3� <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in <br /> H62.20, including well). <br /> 12� <br /> 75/ Op <br /> 1 <br /> f9 <br /> 75'` <br /> Do Not Write in Space Below - F R DEPARTMENT USE ONLY <br /> Date of Application Fees Pai State)/), County- D to d <br /> Permit Issued/Rejected (date) — 3- Issuing Agent Name <br /> Inspection YesyNo Valid# a 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 6/1/76 <br />