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P L. 6 7 state and County State Permit # <br /> 5 <br /> G Permit Application County Peim <br /> for Private Domestic Sewage Systems County /- <br /> DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan ID. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> B. LOCATION: i(,rW 'G, Section / T_y/yN, R /J E (or) W Lot# —City- <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township �J Wi SS <br /> E. TYPE OF OCCUPANCY: Commercial 'Industrial Other (specify) Variance <br /> Single family Duplex No. of Bedrooms / No. of Persons <br /> 0, TYPE OF APPLIANCES: Dista asher VES NO Food Waste Grinder_VES�NO # of Bathrooms — <br /> Automatic Washer VES � NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7J Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation x Addition Replacement_ Prefab Concrete 4 - <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 11 2131Total Absorb Areae?—sq. ft. <br /> New Addition Replacement 'Fill System <br /> Seepage Trench: No. gLinq. Feet Width Depth_Tile Depth No. o res <br /> Seepage Bed: Lengtr C, Width DeptheLrfile Depth f/ " No. of Lines 1, 1y <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size V <br /> Percent slope of land—z—° v 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 SoilesterL <br /> NAME ��fJJ dYP/C' �`r9 �f0 .( C.S # �7 �7 and other information <br /> obtained from Cl' nq ! �> .t.r^ t oowner/builder). p/ <br /> Plumber's Signal MP/MPRSW# Q`� j Phone # <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 /> i <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY 53� S <br /> Date of Application Fees Paid: State /G- County ate <br /> Permit Issued/Re)ested (date) 57-3/7X' Issuing Agent Na J/.y� <br /> Inspection. YesJZ_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) Revised Ddte.6/1/76=� <br />