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Plb 67 State and County State Permit # <br />Permit Application County Perm # _ d <br />for Private Domestic Sewage Systems County <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 />qr <br />1� CZ II At q Q C <br />owner <br />dr S, I� <br />)Q 4 1( h41 [ o <br />B. LOCATION: <br />W '/q y, Section <br />TIf N, R /`/V (or) W <br />Lot# City _ <br />Subdivision <br />Name, nearest <br />road, lake or landmark Blk# <br />Village <br />Township <br />C. TYPE OF <br />OCCUCY: *Commercial <br />*Industrial *Other <br />(specify) *Variance <br />Single family <br />Duplex No. <br />of Bedrooms __ No. <br />of Persons <br />D. TYPE OF APPLIANCES: Dikhyvasher YES --�[— NO Food Waste Grinder YES_XNO # of Bath <br />Automatic Washer YES NO Other (specify) <br />E. SEPTIC TANK CAPACITY 77 (? Total gallons No. of tanks <br />*Holding tank capacity _Total gallons No. of tanks <br />New Installation Addition Replacement_ Prefab Concrete_ <br />*Poured in Place Steel Other (specify) <br />F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) :L 2) 3)Total Absorb Area 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 AC`)' Width / r Depth 6'" Tile Depth tL Y No. of Lines <br />Seepage Pit: Inside diameter Liquid Depth Tile Size `T <br />Percent slope of land —/4-f- LAJ Distance from critical slope <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 Certifi Soi Tester„ <br />NAME tl ((� h (C %�c, rr2 C.S.T. # and other information <br />obtained from /' (owner/uild L <br />Plumber's Signature` MP/MPRSW# 3 d �!I Phone # GT60 yl� <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 />Do Not Write in Space Belo V <br />- ,FOR DEPARTMENT USE ONLY / J/ <br />Date of Application — Fees Paid: State — Cou ate <br />Permit Issued/Rejectu& (date) Issuing Agent Name <br />Inspection Yes L,"' No Valid# ate Recd <br />1. county (white copy) <br />3. <br />owner <br />(green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br />2. state (pink copy) <br />4, <br />plumber <br />(canary copy) <br />