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State and County. State Permit <br /> P L B V`C) /7 Permit Application County P t # {1 <br /> for Private Domestic Sewage Systems County ` <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan ID. # <br /> A. OWNER OF PROPERTY /� /p, Mailing Address: v1 <br /> CY CG—_ S' r�C i /I J `r l� ""I r</i•! � I <br /> B. LOCATION: k % SL;: '/., Section , T��N, R /�, (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township ri � �r j" <br /> Gvr Crf I r �f cls <br /> r_ <br /> C. TYPE OF OCCUPANCY: `Commercial 'Industrial 'Other (specify) Variance <br /> Single family Duplex No. of Bedrooms No, of Persons_ <br /> D. TYPE OF APPLIANCES: Dishwasher VES _NO Food Waste Grinder_YES�'NO # of Bathrooms— <br /> Automatic <br /> athroomsrAutomatic Washer _YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY / J\ 0 U Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation X Addition Replacement Prefab Concrete— <br /> `Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) ,3_Total Absorb Area QIar sq. f[. <br /> New X- Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet_ Width Depth_Tile Depth No. of Trenches <br /> Seepage Bed: Length 3 F , Width _/,�Depth�, Tile Depth ,) y • No. of Lines I <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size - I <br /> Percent slope of land 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 Cert ied $oil Tester, <br /> NAME _ 0 - //J 3 C.S.T. # and other information <br /> obtained from Y rP [y (owner/builder). ��99//// <br /> C <br /> YVL' <br /> Plumber's Si nature - G t 'S <br /> g _ MP/MPRSW# 3 � Phone # - <br /> Plumber's Address tt'�--��- �f 3 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with . <br /> H62.20, including well). r �) <br /> I <br /> s Sept —r —V <br /> tT - <br /> — j <br /> -j11I 1-1 T I ) <br /> Do Not Write in Spacq Below XOR DEPARTMENT USE ONLY <br /> Date of Application — — Fees aid: State , C urs/d' Date <br /> Permit Issued/13epi (date) — _ Issuing Agent Nam/ 7Z/C7— <br /> Inspection Yes //No_ Valid# Oaffi Rac'd I <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 wim <br />