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PLB67 State and County State Permit # Aw <br /> Permit Application County Per ' # <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: $�� 37 <br /> q ilF-rh v t , t-vAA-*14R eD .1 P, S'S30 %+! 93 $LGiGzrl,x,- -TVA� <br /> B. LOCATION: IJ Y4 Ar %, Section 3_S , T R f—f� 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 Duplex No. of Bedrooms i3 No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher _� YES NO Food Waste Grinder_YES O # of Bathrooms <br /> Automatic Washer .3e YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks v <br /> New Installation Addition Replacement_ Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2).__-�3) Total Absorb Area 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 3_5--Width __�Depth <br /> O Tile Depth No. of Lines _ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size r� <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 Certified Soil Tester, <br /> NAME i� . 51/5 k- C.S.T. and other information <br /> obtained from 006 /1E4 . (owner uilder y� <br /> Plumber's Signature kSti MP/MPRSW# Phone <br /> Plumber's Address LX-1 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> LOT- IL-I OV E ' 3 <br /> jet` 2-4�. T <br /> (_!1 Q <br /> t ('S 1 <br /> 5E-V tre= `. . <br /> n zsc <br /> U MP <br /> zsf FROM <br /> u- <br /> Do Not Write in Spac low y OR DEPARTMENT UU QNLY <br /> Date of ication / Fees Paid: State County Date <br /> Perm' Issue Rejec (cat Issuing Agent Name <br /> 77 <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 6/1/76 <br />