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Plb 67 Stave,od 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 ID. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> I t /F ( . jr r s e e 1,'r it <br /> B. LOCATION: -3-& '�< ,'lji '/_, Section / T_C N, R /-N (or) W Lot# t City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township <br /> C. TYPE OF OCCUPANCY: JCoMmercial *In ustrial *Other (specify) Variance <br /> Single family —Y�— Duplex No. of Bedrooms 1-114, No. of Persons__ <br /> D. TYPE OF APPLIANCES: Dishwasher YES X NO Food Waste Grinder_YES NO # of Bathrooms— <br /> Automatic Washer YES _�X NO Other (specify) <br /> E. SEPTIC TANK CAPACITY -i l' 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) JL/CV)A�_C 31 ;4Total Absorb Area sq. ft. <br /> Newl— Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length a� Width /�Depth < Tile Depth No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <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 Certifigd Soil jester, <br /> NAME t r o C.S.T. # 7 �J 7 and other information <br /> obtained from I „!- y•. , y (owner/builder). <br /> Plumber's Signature z-. MP/MPRSW# a\ ^`f Phone # <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> f q <br /> i <br /> l <br /> !f ,l <br /> r <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 /> Revised Date 3/1/75 <br />