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LB <br /> 67 State and County State Permit # O <br /> Permit Application County r t <br /> for Private Domestic Sewage Systems Count <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 /> orTrV�Z tr-ekt d IEJ tea d pry WrSC <br /> B. LOCATION: S w '/. 3w '/., Section /, TV/ N, wI&—, —,b (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark a o S 4 Blk# Village <br /> /e/�'� Township <br /> C TYPE OF OCCUPANCY. *Commercial Industrial Other (specify) Variance <br /> Single family -,Z.- Duplex No. of. B/g_drooms JNo. of Persons_ <br /> o jf_Q(i n <br /> D. SEPTIC TANK CAPACITY —2,T Q Total gallorIV No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in-Place Steel_ Fiberglass Other (specify) <br /> New Installation Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTE Percolation Rat—e - Total Absorb Area sq,ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No.of Linea Ft. Width *-7rDrreof Tre <br /> JJpth Tile depth (top�_No. LL�hes <br /> Seepage Bed:- Length�Width Depth�Tile depth (top) No. of Lines_ <br /> Seepage Pit: Inside diaeter Liquid Depth No.of Seepage Pits <br /> Percent slope of land— (o �— Distance from critical slope <br /> WATER SUPPLY: Private Sloint❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <br /> I, the undersigned, do hereby certify that the information 1 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 C fled Soil Tster, <br /> NAME E r ( ` C.S # � and other information <br /> obtained from Pu (owner/ uilder). ,pC� [� �7 <br /> Plumber's Signature MP/MPRSW# Phone # dg—*LF / <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion 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 /> I I <br /> C) <br /> ? 1.4 <br /> r +2 Xr str�C f <br /> - <br /> u.xrTl tnS <br /> I <br /> OL- <br /> - a - 1 <br /> i <br /> cit <br /> I <br /> I <br />)o Not Write in Space to OR Ed <br /> AND STATE DEPARTMENT U E ONLY <br />)ate of Ication FStateCoun D e <br /> PermiIss ed ejected (date) Issuing Agent Name <br /> nspection Yes No State Valid# Date Recd <br /> I, county (white copy 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> ?. state (pink copy) 4. plumber (canary copy) <br /> Revised Date 7/1/78 <br />