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PLR 6 7 State and County <br />Permit Application <br />for Private Domestic Sewage Systems <br />*DENOTES STATE APPROVAL REQUIRED <br />Date Approval Received from State if Required <br />State Plan I.D. # <br />State Permit # <br />County Pe # <br />County <br />A. OWNER OF PROPERTY Mailing Address: ikirhrl S y� <br />C52 '1--e r- \ 4 F` iT <br />W <br />City <br />Village <br />Township cAr ,yr ys <br />C. TYPE OF OCCUPANCY: "Commercial *Industrial -Other (specify) -Variance <br />Single family _ Duplex No. of Bedrooms No. of Persons_ <br />D. SEPTIC TANK CAPACITY !% _ Total gallons No. of tanks <br />HOLDING TANK CAPACITY Total gallons No. of tanks <br />Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) <br />New Installation Replacement <br />Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) <br />E, EFFLUENT DISPOSAL SYSTEM: Percolation Rate - Total Absorb Area sq. ft. <br />New Replacement Alternate (Specify) <br />Seepage Trench: No. of Line@1 Ft. Width Depth Tile depth ( P4__ No. of Trenches <br />Seepage Bed:XLength 02,�Width %f�r Depth " Tile depth (top) No. of Lines <br />Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits <br />Percent slope of land I ZC, Distance from critical slope <br />WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ <br />Owners name as listed on EH 115 if other than present owner: <br />1, the undersigned, do hereby certify that the information <br />Wisconsin Administrative Code, and that I have sized the <br />by the C tifiep Soil Tester, <br />NAME c, de tc <br />obtained from rc <br />Plumber's Signature i <br />Plumber's Address <br />I have reported is in accord with Section H62.20, <br />effluent disposal system from the EH -115 prepared <br />C.S.T. # �( ='r 7 and other information <br />(owner/builder). <br />IOP/MPRSW# lz� Phone # F — 411 T'`7 <br />B. L ATION: <br />'/4 /J '/4, <br />Section =, T� N, R :0 <br />(or) <br />Subdivision <br />Name, <br />nearest road, lake or landmark <br />Blk# <br />C52 '1--e r- \ 4 F` iT <br />W <br />City <br />Village <br />Township cAr ,yr ys <br />C. TYPE OF OCCUPANCY: "Commercial *Industrial -Other (specify) -Variance <br />Single family _ Duplex No. of Bedrooms No. of Persons_ <br />D. SEPTIC TANK CAPACITY !% _ Total gallons No. of tanks <br />HOLDING TANK CAPACITY Total gallons No. of tanks <br />Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) <br />New Installation Replacement <br />Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) <br />E, EFFLUENT DISPOSAL SYSTEM: Percolation Rate - Total Absorb Area sq. ft. <br />New Replacement Alternate (Specify) <br />Seepage Trench: No. of Line@1 Ft. Width Depth Tile depth ( P4__ No. of Trenches <br />Seepage Bed:XLength 02,�Width %f�r Depth " Tile depth (top) No. of Lines <br />Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits <br />Percent slope of land I ZC, Distance from critical slope <br />WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ <br />Owners name as listed on EH 115 if other than present owner: <br />1, the undersigned, do hereby certify that the information <br />Wisconsin Administrative Code, and that I have sized the <br />by the C tifiep Soil Tester, <br />NAME c, de tc <br />obtained from rc <br />Plumber's Signature i <br />Plumber's Address <br />I have reported is in accord with Section H62.20, <br />effluent disposal system from the EH -115 prepared <br />C.S.T. # �( ='r 7 and other information <br />(owner/builder). <br />IOP/MPRSW# lz� Phone # F — 411 T'`7 <br />