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Plb 67 State End County State Permit # <br /> Permit Application County Permit # <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 /> 0 .±d -- I ti /t 4 al d 1 W 10 n d- Q k a a v1M I n3T n /L4 1 <br /> B. LOCATION: —.Y(-J ''/ , Section 13 T 'YON, R_/.$"gr (or) W Lot# 41 _iry_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village__—�-�_ <br /> uQe �TSO^. <br /> r c Q I— 6-r-Trr-_V o y q J r r Ur /(a E � Township <br /> C .TYPE OF OCCUPANCY.' 'commercial Industrial "Other (specify) Variance <br /> Single family C--'� Duplex No. of Bedrooms No. of Persons- <br /> D. <br /> ersonsD. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES # of Bathrooms <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY / JL d 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) 3) Total Absorb Area sq. ft. <br /> New ge}( Addition Replacement 'Fill System <br /> Seepage Trench: No. Linl aL Feet Width Depth Tile Depth No. of Trenches _ <br /> Seepage Bed: Length _Width / Depth Tile Depth ;k Wr No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size y Of/ <br /> Percent slope of land 1 -3 ` ��t� 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 Ce ied oil Tester, <br /> NAME c -C r e /� go'6 f,i�! -� C.S.T. # 3 7 and other information <br /> obtained from e cl d (owner/builder). pp <br /> Plumber's Signature MP/MPRSW# Phone *_# <br /> Ig <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> 40 c� <br /> / <br /> ° <br /> '00f <br /> i <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State County Date <br /> Permit Issued/Rejected (date) -Issuing Agent Name <br /> Inspection Yes 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 Date 3/1/75 <br />