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Pit, 67 State and County State Permit # <br /> G Permit Application County Perm# <br /> for Private Domestic Sewage Systems County <br /> -. �C1� <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 /> k_ IY14r1_ v1' <br /> � < " <br /> B. LOCATION: W 7. S J '/., Section / _, T 4/Q N,`R_14 k (or) W Lot# --City <br /> Subdivision Name, " nearest .road, lake or landmark Blk# Village - <br /> Township L_rr Lrr�( <br /> VY / �1W LG �C <br /> C. TYPE OF OCCUPANCY: °Commercial ndustrial 'Other (specify) 'Variance <br /> Single family _ Duplex No. of Bedrooms_l� . No. of Persons—'), <br /> D. TYPE OF APPLIANCES: Dishwasher _ YES _ _NO Food Waste. Grinder_YES�O # of Bathrooms-/- <br /> Automatic <br /> athroomsAutomatic Washer J,_VESNO Other (specify) <br /> E. SEPTIC TANK CAPACITY T 0 Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation =A Addition Replacement Prefab Cotten, _k <br /> "Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _ 2)_3) _Total Absorb Area a.c/ 0 sq. it '1 <br /> New—P Addition _ Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width p_Depth_Till, Depth No. of Trenches_ `I( <br /> Seepage Bed: LengthaQLWidlh _Depth . 6 Depth ay_No. of Linesa= r7 <br /> Seepage Pit: Inside diameter Liquid Depth Tile Sizey <br /> Percent slope of land .1 iv Distance from critical slopes— <br /> I <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 C id Soil Tester, <br /> NAMEd�� rc k _ -eP/1 /n�' C.S.T. # 3 and other information ' <br /> obtained from r' p K3'e�r (.wine /builder). <br /> Plumber's Signature P/MPRSW# <br /> A$ Phone # �/f <br /> 1 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). 1 <br /> a <br /> I. 1 <br /> 5 <br /> i i <br /> A-0 <br /> Do Not Write in Spac Below FOR DEPART EN USE ONLY <br /> Date of Application tl-/- Fees Paid: State=County— <br /> - D to 4-x ' <br /> Permit Issued/fhttwitand (date) Issuing Agent Name. <br /> Inspection Yes ✓ No_ Valid# - <br /> --� te .Recd <br /> �7 <br /> 1. county (white copy) 3. owner (green copy) <br /> 2. state (pink copy) DIVISION OF HEALTH, P.O. BOX 309, -MADISON, WI 153701 <br /> 4. plumber (canary copy) - - <br /> I <br /> Revised Date 3/1/75 <br />