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PLB67 <br />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 />A. OWNER OF PROPERTY Mailing Address: <br />State Permit # <br />County Pe - # <br />County <br />.170 <br />B. LOCATION.'/,fib '/4, Section 1j T�QN, Rj �-(or) W Lot# City_ <br />Subdivision Name, ne�rest road,lake Ylar aark <br />Blk#�e <br />yl,- C, Q <br />Village <br />Township _(1((ig111 <br />C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br />Single family A"'_ Duplex No. of Bedrooms No. of Persons_ <br />D. TYPE OF APPLIANCES: Dishwasher YES _Y NO Food Waste Grinder_YES_,)<"NO # of Bath <br />Automatic Washer YES,<NO Other (specify) <br />L. SEPTIC TANK CAPACITY 7-S-0 Total gallons No. of tanks <br />*Holding tank capacity Total gallons No. of tanks <br />New Installation ,kl Addition Replacement_ Prefab Concrete <br />*Poured in Place Steel Other (specify) <br />F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) -j- 2)__.I_3) _Total Absorb Area4ll/Q sq. ft. <br />New Addition Replacement *Fill System <br />Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br />Seepage Bed: Length Width i_ Depth " Tile Depth 7Y ` No. of Lines �_ t <br />Seepage Pit: Inside diameter Liquid Depth Tile Size 4 <br />Percent slope of land q 19 Distance from critical sl <br />ope <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 Ce ified Soil Tester, <br />NAME ko Wv_ ets U -e,l� C.S.T. # (C 1(o and other information <br />obtained from <br />(owner/builder). <br />Plumber's Signature MP PRSW# �� ��� Phone #�k.e - ;72 0j <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 />I <br />H0.Cu <br />5 • <br />a1ov <br />W <br />TLL <br />• Z7 t _ ! <br />Y <br />Ot �-- <br />�►Ndec�rjv»el _--�— <br />r. <br />�b <br />V <br />l60 <br />< <br />�•e6`j1 ¢cJc,3 <br />Not Write in Space I OR DEPARTMENT Uj� E ONLY t <br />ate of cation F s Paid: State / County D to <br />,TTM (Slue ejecte (dat <br />Issuing Agent Name � <br />spection Yes <br />N0 Valid# Date Rec d <br />county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br />0 <br />