Laserfiche WebLink
PLS 67Ofory <br /> State and Count State Pertou <br /> I Permit Application CountyPe Private Domestic Sewage Systems County <br /> I <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 /> ?3G_ 2NHX0 G/z"Lli, - SS/4 CZ6;vaxn 9kwy �o..tiaio-IL na SSY3� <br /> B. LOCATION: '/. $ %, Section 'i, T�N, R�E-.{ad W l _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township f90/ piC/ <br /> C. TYPE OF OCCUPANCY: 'Commercial 'Industrial 'Other (specify) 'Veriance <br /> Single family I Duplex No. of Bedrooms No. of Persons 7, <br /> D. SEPTIC TANK CAPACITY 7f6 Total gallons No. of tanks <br /> 1 HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete ✓ Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation Replacement <br /> Lift Pump Tank or Siphon Chamber 7� Total gallons Prefab concrete poured in-Place—Other(Specify)!��M­e­x. I <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 3—�-3Total Absorb Area `/ /c sq. ft. <br /> New Replacement r� Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft WidN�Depth_Tile depth (top—No.of Trenches <br /> Seepage Bed: ?.i­'C Length /�'"•' Widths DepthTile depth (top)/",No. of Line ?' I <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of lands—. Distance from critical slope l <br /> WATER SUPPLY: Private. Joint❑ Community❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: ' <br /> 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,f <br /> NAME /0A. 10 St GST. a S-SV 2-/ and other information <br /> obtained from e tri' C_ (owner/builder). <br /> Plumber's Signature MP/MPRSW# S V 2/ Phone ar <br /> Plumber's Address 7-/- �- /%! Si,r/mit. �C/iSLo.��. •� <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 /> t(�lr <br /> IV.s<itya.'1>1o' <br /> '� '�•vea-q,�ra D/s Irtrdo%.o.y 00 <br /> jgrrurn.r i��'Pac-Sen-ao <br /> le ` <br /> SyrT�.. . •SI .'C- B�v_P.::.p�� �1 <br /> A t-o <br /> F _�� _ <br /> w <br /> Fort, <br /> PE,i c11 � <br /> 0 <br /> IL <br /> I <br /> 1 1 1 1 T Ill it 1 11111111 I I I I I <br /> Do Not Write in Space ow FOR COUNTY AND STATE DEPARTMENT USE ONLY �Q <br /> Date of A cation F Paid: State j . County -y--;�- to <br /> Permit s ued/ electe dat 1 Issuing Agent Name/,,/ t r� Q/r _ <br /> Inspection Yes No _ State Valid# Date Recd C' <br /> 1, county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISONAWI 53701 <br /> 2. state (pink copy) 4. plumber (canary copy) / <br /> -"Revised Dat�7/1/78 <br />