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b- - <br /> Plb 67 StateatiSCounty - State Permit # <br /> Permit Application County <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 ' I- �) 1 ' )- Mailing Address: I <br /> Cf �\h)tI N.Sd L'\ _��/ / J� - �ry 19'V:fl `Iy /I l/ �1` '.A.-f �NY//ilt: <br /> B. LOCATION: _ f=% SF- %, Section , T_'/ON'. RLg (or) W Lot# —City <br /> Subdivision Name, / nearest road, lake or landmark Blk# Village <br /> l. d Township 4 z'�Seh <br /> 4 q <br /> C. TYPE OF OCCUPANCY: Commercial 'Industrial 'Other (specify) 'Variance <br /> Single family Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCkS: Dishwasher VES X NO Food Waste Grinder_YES_NO # of Bathrooms <br /> —17 <br /> Automatic Washer_VES NO Other (specify) ' <br /> E. SEPTIC TANK CAPACITY `I s O Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks —. <br /> New Installation X Addition Replacement Prefab Concrete <br /> 'Poured in Place Steel Other (specify) _ <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 1 2) S "3) _�Total .Absorb Area sq, ft. <br /> Newx Addition Replacement 'Fill System <br /> Seepage Trench: No. Ip,in`j� Feet - Width Depth_Tile Depth No. OL <br /> Seepage .Bed: Length_QC( Width / f'Depth 3 6" Tile Depth 2 9' No. of Lines <br /> Seepage Pit: Inside diameter - Liquid Depth Tile Size y <br /> Percent slope of land 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 1 have sized the effluent disposal system from the EH 115 prepared <br /> by the Certify SQiI Tester, `/ " t <br /> NAMEd r r--, C <br /> #J J/;I/q : C.S.T. # ' / 3 7 and other information <br /> obtained from r `LCC n f••' (owner/builder). <br /> Plumber's Signature_u _ - /. . MP/MPflSW# �� 100 ' Phone #.YAC — 1(CJ7 <br /> PLAN VIEW: Rovide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> I ( I I I LI I 1 1 I -I Ii-F I I <br /> - -i=l�"70 <br /> ! � I i PlK '�•�f-1 lid`' i� !� -I l ( <br /> i _ 1 I- jj_ _ <br /> i - <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State�County to — <br /> Permit Issued/Rejected' (date) �J—/�-7 7 Issuing Agent Name <br /> Inspection Ves_L,�No Valid# ' ff.. 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 />