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FILB67 State and County State Permit <br /> Permit Application County Per # <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 <br /> � Mailing Address: <br /> C) <br /> i o 8 /4(r-[C 1 <br /> B. LOCATION: 0/—�j _'/e Y<, Section , TnN, R E—der) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance _ <br /> Single family X Duplex No. of Bedrooms Z No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder_YES�NO # of Bathrooms <br /> Automatic Washer YES NO ther (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 Concrete_ <br /> *Poured in Place Steel Other (specify) <br /> F. EFFL` ENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft. <br /> New / Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet . Width Depth Til, Aepth No. of Trenches <br /> am <br /> Seepage Bed: Length 4 Width ` Depth Tile Depth No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size C <br /> Percent slope of land Distance from critical slope <br /> jF <br /> 1, 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 Certifreo Soil Tester, <br /> NAME Piat, C.S.T. #SS ysV and other information <br /> obtained from (owner/builder). ��,(/ <br /> Plumber's Signature ` Mp/pFp # S� is Phone *0' 10 — X3 3 <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> Nelson Aobr 1,1), <br /> V),*,If IPA Q54-_6eQ,1' )e"I- <br /> 0-�S`f ro vM Z Py*f C 4-a K k <br /> m, 2ca' d- �5-a ' -Fra vx seepive L4.�, <br /> `t 4� *ti jvZ <br /> 10 <br /> ScQpa �b CT Vw-wf <br /> _ r9 ti <br /> st /�rta�1� <br /> -rns�>t <br /> Do Not Write in Space Below - F R DEPARTMENTS� E ONLY / <br /> Date of Application Fees Paid: State County e J <br /> Permit Issued/ ied (date) J _Issuing Agent Name <br /> Inspection Yes_LZNo Valid# Date ec'd <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 6/1/76 <br />