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PState and County State Permit # 113 V5 <br /> Permit Application County Permit # 9.3 75? <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 PROPELRTY /J / Mailing Addd/ress: <br /> //_— <br /> B. LOCATION: '/n .SF '/, Section , T 0 N, R/� V (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> //�� <br /> t 7 <br /> 40 ey 1 /5- 4 0. h-v Township <br /> C. TYPE OF OCCUPANCY: *Commercial "Industrial `Other (specify) 'Variance <br /> Single family _X'-- Duplex No. of Bedrooms No. of Persons_ <br /> D. SEPTIC TANK CAPACITY :ZZL-U oral gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete)_ Poured-in-Place Steel Fiberglass Other (specify) <br /> �/ <br /> New Installation /� Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete_Poured-in-PlaceOther (Specify) <br /> E. EFFLU NT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. <br /> New Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft.—Width—Depth—Tile depth (top) No.of Trenches <br /> Seepage Bed: _Length ifs r Width Depth Ylf Tile depth (top) " No.of Lines ^� <br /> Seepage Pit: Inside dizIrriLter Liquid Depth No.of Seepage Pits <br /> Percent slope of land / q b _S_ Distance from critical slope <br /> WATER SUPPLY: PrivateJoint ❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <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 Cer;ktpci foil T este <br /> NAME h ,1 G i'm C C.S.T. # '� 7 and other information <br /> obtained from-7-13!m4S Y C6 19. f% (owner/builder). <br /> Plumber's SignatureP/MPRSW# 0 3 o S y Phone # 6 <br /> Plumber's Address <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not been drilled please indicate. <br /> Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY n <br /> Date of A lication y:�/��/ Fees Paid: State Cou,,��nty .ai�o ,,D/atee�4k ./' -�,3, �Qfl <br /> Permit ssue ejected (date) Dauf'a3./9�/ Issuing Agent Name&_ .z7. SLLdsLCe.uG4� <br /> Inspection Yes No 'C State 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 7/1/78 <br />