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Plb 67 w •State and County State Permit # 3j <br /> Permit Application County Per 't # — <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 /> 3 v64 <br /> B. LOCATION: 1Vto% '/a, Section T <�o N. R /,Z E (or) W Lot# Cr City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> cg. r rte' �1_C ¢ Township j'#GJT.Po; <br /> C. TYPE OF OCCUPANCY: *Commefcial *Industrial U *Other (specify) *Variance <br /> Single family Duplex No. of Bedrooms No. of Persons__ <br /> D. TYPE OF APPLIANCES: Di hwasher YES _-_%_NO Food Waste Grinder YES_,,&NO # of Bathrooms_ <br /> Automatic Washer YES Y NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7;?57 0 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 Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) ! Z 3) )A Total Absorb Area sq. ft. <br /> New Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. Trenches_ <br /> Seepage Bed: Length P6rWidth�Depth `/ Tile Depth VS! No. of Lines ' L! <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land 7 `76 So t 7`� Distance from critical slope s'--- <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 ' 'ed Soil Tester, /� <br /> NAME a c{�+ r c � t f" // C r C # `y and other information <br /> r� <br /> obtained from P! r- wn /builder►.© (9 `> Phone # "]J a - I e r7 <br /> Plumber's Signature a� MP/MPRSW# <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> - �- <br /> q , <br /> AL <br /> l <br /> Zs• Dwc' ^v <br /> i <br /> a <br /> f <br /> Do Not Write in Space elow - F R D ARTMENT USE ONLY <br /> Date of Application — & —� Fees Paid: State Coun - ate �? <br /> Permit Issued/Rs (date) Issuing Agent Name <br /> Inspection Yes_L,�'No Valid# . ate 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 3/1/75 <br />