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B <br /> State and County State Permit # <br /> fffLLL r Permit Application Conr Pont Ar <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 /> �+1 <br /> Inu'. n s Sl�oP � / o 3y �Q L sf sI <br /> B. LOCATION. L'/. 5 W /., Section T C,/O N, R: � (or) W Lat# LL_City <br /> Subdivision Name, // nearest road, lake or landmark Blk# Village <br /> Ar r4 lPoJ (T^^P Ceh Township YC ' <br /> C. TYPE OF OCCUPANCY: Commercial 'Industrial `Other (specify) 'Variance <br /> Single family X Duplex No. of Bedrooms �U No. of Persons �-- <br /> D. SEPTIC TANK CAPACITY 7 T Q Total gallons Noof tanks _L - <br /> HOLDINGTANKCAPACITY Total gallons No. of tanks <br /> Prefab concrete XV Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation. ^ Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallone Prefab concrete—Poured in PlaceOther(Specify)_ . <br /> E EFFLUENT DISPOSAL SYSTEM: Percolafion Rate =��Totyi Absorb Anea y-� ` �sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of L neat Ft Width Depth_Tile depth (topL—No.of Trenches_ <br /> Seepage Bed:—�Length�Width I t1'' Depth `3U rr Tile depth (top) qrtE�' No. of Line -3 <br /> Seepage Pit: Inside of amer Liquid Depth No. of Seepage Pits <br /> Percent slope of land n /U Distance from critical slope <br /> WATER SUPPLY: Private lz+'Toint❑ 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 tlisposal system from the EH115prepared - <br /> by the Certified 4011 T _ ,/ <br /> NAME /` e [�t c t h S C.S.T. iF ] •.>' and other information <br /> obtained from e t f' $ 4r c r (owner/builder)- <br /> Plumber's Signature /{' G-z(,Lt..�_�^ (�--e{y- MP/MPRSW# d-IPO Phone # <br /> Plumber's Address— L �— 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 /> I <br /> � I . <br /> 1 <br /> I <br /> Do Not Write in Space Below - FOR COUNTYANDSTATE DEPARTMENT USE ONLY ��QQ <br /> Date of A )kation ,5--A2-X/ Fees Paid State )°/ County a / Date <br /> Permit Issue Rejected (date) 3/9F/ Issuing Agent Name 1z-•S2G146G4✓ v <br /> Inspection Yes No / _ State Validffi 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) <br /> Revised Date 7/1/78 <br />