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Ptd 67 State and County State Permit # <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: <br /> TO fiein ,rn j/lfutr 0 <br /> B. LOCATION: y5-e '/< '/<, Section �q, T__YCN, R1r& (or) W Lot# City <br /> Subdivision Name, nearest +'road, lake or landmark Blk# Village <br /> Township fJ <br /> C. TYPE OF OCCUPAANCY: {Commercial "Industrial `Other (specify) `Variance <br /> Single family /1 Duplex No. of Bedrooms -No. of Persons <br /> D. SEPTIC TANK CAPACITY /a UL 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 x Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete_Poured-in-Place—Other (Specify) <br /> E. EFFLU T DISPOSAL SYSTEM: Percolation Rate — Total Absorb Area f _ sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No.of Trenches <br /> Seepage Bed:_ �Length— Z33 �Width Depth `•Tile depth (top) F'` No.of Lines 2 <br /> Seepage Pit: Inside/r�ipia er Liquid Depth No.of Seepage Pits <br /> Percent slope of land / p !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 Cert d oil Tester 1 <br /> NAME 'C NIC -T' Q • f j C.S.T. # 'y :� -7 and other information <br /> obtained from 0 t h (owner/builder). r, ,ry / WS-7— <br /> Plumber <br /> , �y <br /> Plumber's Signature MP/MPRSW# � 30 -/ Phone #p6p- 7�S / <br /> Plumber's Address S 4 <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 B OR OUNTY AND STATE DEPARTMENT U ONLY <br /> Date otion ees a State Coun ate <br /> Perm i sued/ jetted date Issuing Agent Name <br /> Inspection Yes No 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 />