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h -c— <br /> �'/'� f State Permit it Or 56 7 <br /> vN Siete a:d Sounty IIS <br /> Permit Application County Per t # <br /> for Private Domestic Sewage Systems County <br /> 'DENOTES STATE APPROVAL REOUIRED ' <br /> Data Approval Received from State if Required State Plan I.D. a <br /> A. OWNER OF PROPERTY Mailing Address: <br /> r <7 r�FO 7 <br /> g L TT1O1N� '/. '/., Section ,`�, I _- E (or�W 1_ot# _f_.-ny <br /> ( Y XT/ lake ur landmark Blk# Village _ <br /> Subdivision Name, nearest road, <br /> Township ¢� o �A/1 H <br /> C. TYPE OF OCCUPANCY: 'Commercial Industrial Other (specify) 'Variance <br /> Single family DUPle% No. of Bedrooms Q No. of Persons__ <br /> D. TYPE OF APPLIANCES: Dishivahrrr _YES _NO Food Waste Grinder_YES�NO­ # of. Bathrooms <br /> Automatic Washer _YES 4rv0 Other (specify) <br /> E. SEPTIC TANK CAPACITY I Total gallons No. of tanks _ / ' <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation /-� Addition Replacement Prefab Concrete <br /> I <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)� 2)_ij_,3) Total Absorb Area /C sq. ft. <br /> New�ddition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width _ DepthTile Depth No. of Trenches_ <br /> Seepage Bed: Length ?,s,Wmth Z,2 h <br /> • Depth Tile Dept " No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land d i' Distance from critical sloped iGYi <br /> 1, 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 Certiffed Soil. Nester, <br /> NAME -�' .c. /_[//1 P>�[p C.S.T. # ,�_5 c/.� r and other information <br /> obtained from_ FF At towner/builder. / I( <br /> Plumber's Signature A- / Tom. MP/MPRSW# / ' ��Phone <br /> Plumber's Acidities! l/�'// f 7 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> - J <br /> J . _ .t. . ..- .. - - -� — - -f.. - <br /> i <br /> I T <br /> r <br /> r Y r <br /> t <br /> t s C r FE <br /> I ` <br /> T. T <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY <br /> Dene of Application - 7 Fees Paid: State )0,00 Cou.n(t�y Dat <br /> Permit Issued7Re—fiCi2a' (date) 'O '7 Issuing Agent Name ,lA 'Date Yes _ Valid# • N Date Recd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701' <br /> 2. stare Ipink copy). 4, plumber (canary copy) - <br /> _- -- - Revised Date 6/1/76; <br />