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IPPI 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 ►P,IROPERTY Mailing Address: sylt/ <br /> B. LOCATION: — % Y4, Section T Y4 N, R fll� P (or) WLot# City <br /> Subdivision Name, nearest road, lake or landmark Blk*A—vi Village <br /> Township <br /> C. TYPE OF OCCUPANCY: CommercialIndustrial "Other (specify) `Variance <br /> Single family Duplex No. of Bedrooms —r,oC No, of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder—YES NO # of Bathrooms <br /> Automatic Washer _YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation _( Addition Replacement_ Prefab ConcreteZ <br /> `Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) O 2) ) otal Absorb Areasq. ft. <br /> New Addition Replacement 'Fill System <br /> Seepage Trench: No. �Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length Q0' Width /�0'1 Depth 3A Tile Depth ay " No. of Lines o'l rt <br /> Seepage Pit: Inside diameterLiquid Depth Tile Size IV <br /> - <br /> Percent slope of lands 70Distance 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 Cenim Spit Tes r, <br /> NAME C.S.T. # �/ 3 / <br /> and other information <br /> obtained from &4qw 4. (owner/builder), p pp/// y <br /> Plumber's Signature MP/MPRSW# 3 d f/ Phone * W- 4crs 1 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> I I I <br /> I <br /> I <br /> I 1 <br /> i <br /> � t _._ ...� � <br /> � I � �I I I I <br /> t <br /> I I <br /> + _ <br /> I <br /> I <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State County 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) <br />