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p �I State and County State Permit # 14016 f <br /> Permit Application County Perm}}'�# <br /> for Private Domestic Sewage Systems County <br /> *DENOTES STAT APPROVAL REQUIRED <br /> Date Approval Re eived from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> i� <br /> � �� #`+►/ 30� 2-T 1 SIleeAte 13 e / 3 �,E s-s- 97 Y <br /> B. LOCA ION. N —/< '4, Section T2 N, R/ <br /> - / (or) Lot# City <br /> Subdivision fame, 1,e94oRt ✓D4earest road, lake or landmark 61k# Village <br /> C S!✓� Township h7f'Ps✓ <br /> C. TYPE OF O CUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family)—/, _ Duplex No. of Bedrooms __No. of Persons Z <br /> I <br /> D. TYPE OF APLIANCES: Dishwasher YES NO Food Waste Grinder YES-KNO # of Bathrooms—/ <br /> Automatic Wsher YES NO Other (specify NON— <br /> E. SEPTIC TAN NC CAPACITY '77_Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation >( Addition-_ Replacement_ Prefab Concrete <br /> *Poured in Place Steel X Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area - 4sq. ft. <br /> New Ad ition Replacement *Fill System <br /> Seepage TrencF : No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length ;Z-L— <br /> Width Depth�4—Tile Depth�_No- of Lines <br /> Seepage Pit: yrnside diameter Liquid Depth Tile Size _ <br /> Percent slope of land Distance from critical slop <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 T ter, <br /> NAME D f 0 <br /> K- II✓S C.S.T. # 3 ? and other information <br /> obtained from (owner/builde <br /> Plumber's Signature Mp/MP 7 i Phone #-31(1 <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> /10 T 3 C'S M <br /> fi <br /> a, " <br /> r O ¢11 � j0 ? L S7� <br /> 9 <br /> OOH <br /> Do Not Wr Ie in Spe Below - FOR DEPARTMENT PSE ONLY r� <br /> Date of Application Fees Paid. State d Count Date <br /> Permit Issued/R�ectatT (date) gIssuing Agent Nam <br /> Inspection Yes_jZNo Valid# F Aate 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 />