Laserfiche WebLink
PLB67'Illi <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 />State Permit #/ Q / <br />County Permit <br />County <br />A. OWNER OF PROPERTY <br />certify that the <br />Mailing Address: <br />1 have reported is in accord with Section H62.20, <br />Ae Tie t --'To r., e c <br />B. LOCATION: 7W Y, f' Y., Section <br />S 1 Lv <br />T N, R <br />J Ae r <br />(or) W Lot# <br />—City_ <br />Subdivision Name, nearest road, <br />lake or landmark <br />Blk# <br />Village <br />50 4 rry <br />M h <br />� tI n <br />I �' j� <br />S <br />Township f.{ i(/ 9)I� <br />-- <br />C TYPE <br />o�^ <br />owner/build— er--). <br />OF OCCUPANCY. Commercial Industrial *Other (specify) *Variance <br />Single family_ Duplex No. of Bedrooms No. of Persons <br />D. TYPE OF APPLIANCES: Dish asher YES X NO Food Waste GrinderYES x NO # of Bathrooms__ <br />Automatic Washer YES NO Other (specify) <br />E. SEPTIC TANK CAPACITY -7,3-0 ,3'0 Total gallons No. of tanks <br />*Holding tank capacity Total gallons No. of tanks <br />New Installation x Addition Replacement _ Prefab Concrete <br />*Poured in Place Steel Other (specify) <br />F. EFFLU NT DISPOSAL SYSTEM: Percolation Rate 1) 2)_-QL-3) Total Absorb Area sq. ft. <br />New A Addition Replacement *Fill System <br />Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _ <br />Seepage Bed: Length A 4 Width _1 Depth 3(v " Tile Depth '� C/ No. of Lines 3 <br />Seepage Pit: Inside diameter Liquid Depth Tile Size <br />Percent slope of land ; Distance from critical slope ems----� <br />I, the undersigned, do hereby <br />certify that the <br />information <br />1 have reported is in accord with Section H62.20, <br />Wisconsin Administrative Code, <br />and that I have <br />sized the <br />effluent disposal system from the EH -115 prepared <br />by the Ce 'fled /Soil Tester, <br />NAME U c1 +r t C <br />Z A—f <br />S <br />C.S.T. # 4/ 7 and other information <br />obtained fromr <br />o�^ <br />owner/build— er--). <br />Plumber's Signature <br />MP/MPR d 3 (� �i f Phone # l <br />Plumber's Address L <br />S' <br />PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br />H62.20, including well). <br />�f <br />7r --- :- =�� <br />,f <br />Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br />Date of Application Fees Paid: State County <br />Permit Issued/Rejected (date) _Issuing Agent Name <br />Date <br />�I <br />Inspection Yes No Valid# Date Recd <br />I. 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 coov) <br />