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Plb 67 State and 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 /> .�� a ►�, �. � c. /� h / r �o S' � E 1 � �.a /S" wise ,. <br /> B. LOCATION: $'W '/< Al €, Y<, Section if, T3t N, R / (or) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# __ Village �y <br /> Township <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial ^^ *Other (specify) *Variance <br /> Single family Duplex No. of Bedrooms tx No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES --X—NO Food Waste GrinderYES—XNO # of Bathrooms_ <br /> Automatic Washer YES 4—NO Other (specify) <br /> E. SEPTIC TANK CAPACITY S0 Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition Replacement `/_ Prefab Concrete zt <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _X_ 2) 3) _Total Absorb Area A if sq. ft. <br /> New—Y Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _ <br /> Seepage Bed: Length IyV Width IV Depth Tile Depth No. of Lines a'- <br /> y „ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size` <br /> Percent slope of land cJ' "7o 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/ Soil Tester, <br /> NAME 11 0 tr rt r- r C,t- J4 r C.S.T. # L/3 7 and other information <br /> obtained from r .,r So cl (o nn r/h-mild-wA.� 3CS (� <br /> Plumber's Signature Com.-c..f ! ..L MP/MPRSW# y Phone # 1664- / r--r7 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> . . .. _ x . <br /> 1. \1t` <br /> + tvV <br /> n <br /> Do Not Write in Space Below - FOR DEPARTM USE ONLY <br /> Date of Application Fees Paid: Ste ._—GvmSfy 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 />