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6 State and County State Permit # <br /> �/ Permit Application County Permr <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 /> Rrr s`s Y'7 <br /> _oDw� r � erSJ� l7 ,j6TC �v. <br /> B. LOCATION: -T %, Section _ T_yQ N, R_/!fie (or) W Lo[# _ City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village ./��/—_ <br /> ` / J Township SG o Ll— <br /> /�4 It SC C syx {�Q�`Q. <br /> C. TYPE OF OCCUPANCY: 'Commercial 'Industrial 'Other (specify) 'Variance <br /> Single family --�( Duplex No. of Bedrooms e1, No. of Persons--G— <br /> D. TYPE OF APPLIANCES: Dishwasher VES _)NO Food Waste Grinder_YES_XNO # of Bathrooms_/ <br /> Automatic Washer—YES Y NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7-PO Total gallons No. of tanks _ <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation _Yj Addition Replacement Prefab Concrete X <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 11 3 21 3 3) :3E:Total Absorb Area sq. ft. <br /> NewX_. Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width DepthTile Depth No. of Trenches <br /> Seepage Bed: Length . 6 y s Width / r Depth G Tile Depih�Yr� No. of Lines J9 /! <br /> 7 (/ <br /> Seepage Pit: Inside diameter y� Liquid Depth Tile Size 1 <br /> Percent slope of land_! O Distance from critical slope 777 - II <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 EH115prepared <br /> by the Certif ted Tester, z� <br /> NAME Lz,F-,0 t^r c h— �j /1 j iy S C.S.T. # �� 3 7 and other information <br /> obtained from e bT e•` re owner ilderl. !�' <br /> Plumber's Signature _/�O l,w—�i - n MP/MPRSW# e Phone #jg—gl S7 <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 /> Tt <br /> f <br /> Tj <br /> 1 I I <br /> -- <br /> ) <br /> Do Not Write in Space Below F R DEPARTMENT UtSE ONLY _ <br /> Date of Application C- Fees P�ai/d: State /0 County — <br /> Permit IssuedJReic � Idate) LC �+S-7b Issuing Agent Name��/� <br /> Inspection Ves_�No _ Valid# / to Recd <br /> 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 j <br /> 2 state (pink copy) 4. plumber (canary copy) Revised Data 6/1/76 <br />