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PLB67 -37 <br />' State and County State Permit # <br />Permit Application County Per # 69 <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 />114Z- E. SWORC-7 .26,30 t c�ERsoA1 Si AIE', /1'l AZ5S n?l'tiAv 554118 <br />B. LOCATION: _6W % &46 %, Section , T O N, R�,# (or) W Lot# City _ <br />Subdivision Name, nearest road, lake or landmark Blk# Village <br />+, f 2 //'�// Township 7i¢CL<SoA-,/ <br />L�$� d%� �f7+�i��/icJ��( ViC�+��2 ��ul�Sr� <br />C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br />Single family Duplex No. of Bedrooms No. of Persons ., <br />D. TYPE OF APPLIANCES: Dishwasher YES X, NO Food Waste Grinder YES 5<,NO # of Bathrooms_L <br />Automatic Washer YES __;?�,VO Other (specify) <br />E. SEPTIC TANK CAPACITY 7_S,<=) Total gallons No. of tanks <br />*Holding tank capacity Total gallons No. of tanks <br />New Installation i` Addition_ Replacement_ Prefab Concrete <br />*Poured in Place Steel Other (specify) <br />F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2, 2);2 3) Total Absorb Area 'yId sq. ft. <br />New %'-Addition Replacement *Fill System <br />Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br />Seepage Bed: Length 13 Width 6$ Depth 3(,o Tile Depth I-- No. of Lines <br />Seepage Pit: Inside diameter Liquid Depth Tile Size <br />Percent slope of land ` to t' Distance from critical slope_ <br />1, the undersigned, do hereby <br />certify that the information <br />I have reported is in accord <br />with Section H62.20, <br />Wisconsin Administrative Code, <br />and that I have sized the <br />effluent disposal system from <br />the EH-115 prepared <br />by the Certified Soil Tester, <br />NAME <br />t/ <br />C.S.T. # and <br />other information <br />obtained from ,9-4- <br />- <br />(ownerA6ni+@ler). <br />Plumber's Signature <br />/MPRSW# �7oZ <br />Phone <br />Plumber's Address <br />Gr/%• <br />3 <br />PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br />H62.20, including well). <br />D p!� <br />r <br />A <br />r3v' INS N <br />9 Alt <br />Do Nol Write in Space Below - OR DEPARTMENT USE ONLY <br />Date o Application &- -- Fees Paid: State /0— County Qate s� <br />Permit Issued/8e}esV@:6 (;ate)h--iIssuing Agent Name <br />244d— <br />Inspection Yes V No Valid# ate Rec'd <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) n y G„ MR <br />