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r P L B 6 7 ti State and County State Permit # 3 � <br /> ���/// fir/ r Permit Application County Fermitjf � <br /> for Private Domestic Sewage Systems County / <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State If Required State Plan I.D. a <br /> A. /OWNER OFF PROPERTY n Mailing Address: n / <br /> i/ vnc /ri STy r ii Vr cZ S70 !J'e �G4.` OPt S � /'GC L. LJvtr /Ih- <br /> B. LOCATION: = '/. .0/., Section Jr, T/N, R( II lnrl W LntaY City <br /> Subdivision Name, nearest road. lake or landmark Blkx Village <br /> Township <S Wr f C <br /> 7vcy, lir � jGos <br /> C. TYPE OF OCCUPANCY: `Comme¢i 'Industr lal 'Other (specify) 'Variance <br /> Single family Duplex No. of Bedrooms No. of Persons •�- <br /> D_ SEPTIC TANK CAPACITY _7.SCr Time gallons No. of ranks <br /> HOLDING TANK CAPACITY Total gallons No. of ranks ' <br /> Prefab concrete Poured-in Place ✓ Steel Fiberglass Other (specify) I <br /> New Installation Replacement /� <br /> Lift Pump Tank or Siphon Chamber Total gallon: Prefab concrete—Poured in Place—Other (Specify)_ <br /> E. EFFLUENT DISPOSAL SYSTEMPercola =1 <br /> tion Rate -4- Total Absorb Area �S sq. ft. <br /> New Replacement X Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (to d No.of Trenches_ <br /> Seepage Bed: Length Width Depth Tile depth (top) No. of Line <br /> Seepage Pit:XInside di�^eter_�7' Liquid Depth -r I No.of Seepage Pits <br /> Percent slope of land C) /•• Distance from critical slope a O <br /> WATER SUPPLY: Private❑ Joint 0 Community 0 Municipal 0 <br /> Owners name as listed on EH 115 if other than present owner: <br /> I, the undersigned, do hereby certify chat 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 preparetl - <br /> by the CertiI d Sit Tester, p <br /> NAME O k,�• c P t C.S.T. a L/ / and other information ) <br /> obtained from Jr, o IIgrU " (own /builder f� 99// <br /> Plumber's Signature ° h - MP/MPRSW# CSS/ Phone gOtG'IO- <br /> Plumber'v FrlAres �.\ l.]-^JIG. f Jill�^4 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well Ioca- <br /> non 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 /> it <br /> —Int � I <br /> LN <br /> 11 TIC <br /> -T I <br /> �I - <br /> . r a - <br /> Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY_\ A. v' J <br /> Date of Application Fees Paid: State //)� Counyy, atel��(j—� .�. 1 <br /> Permit Issued/Hajvese9 (date) !� Issuing Agent Name //% , �. It <br /> Inspection Yes Z-�No State Valid# !/4Yele flec'd, <br /> 1. county (will. copy) 3. owner (green copy) DIVISION OF HEALTH, Pg —N <br /> 2 (canary copy). state (pink copy) 0. plumber _ .O. BOX 309, MADISON, WI 53761 .I <br /> :�� - <br /> _ _ Revised Date 7/1/78 <br />