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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 /> 1, 7 <br /> W G Q C e I n d iT ra im /0 h a 0 N C V)-Ag f/i S c r• 5 f B L G 101 a /Lt r 7 <br /> B. LOCATION: % tiE %, Section M, T iLON, R/Y V (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> -5�► )'t cj -71' P 11 Township (" Q <br /> C. TYPE OF OCCUPANCY: Commercial "Industrial 'Other (specify) "Variance <br /> Single family _X_ Duplex No. of Bedrooms a No. of Persons 3 <br /> D. TYPE OF APPLIANCES: Dishwasher YES )(' NO Food Waste Grinder—YES__kN0 # of Bathrooms <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY /a U C9 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. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) QJ32)_4T' 3) "Total Absorb Area Q sq. ft. <br /> New Addition Replacement `Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length vZy' Width /a' Depth " Tile Depth R 9" No. of Lines 'aL <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land Q Ie 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 CertifSoil Tester, <br /> NAME 911M r 1 C. )114 C jo /) 1"1 S C.S.T. # 7 and other information <br /> obtained from �`'� ' C C P (owner/ uil <br /> Plumber's Signature q MP/MPRSW# d �?d Phone # dN6 r r 7 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> A ' <br /> "' a <br /> 11: f <br /> part /s 1�` r1Xe�y 3� <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) Revised Date 3/1/75 <br />