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PLB67 State and County State Permit # <br /> Permit Application County Permit # <br /> for Private Domestic Sewage Systems County er,3,el <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 /> 6;4�wq 14�,�J-r 4194-,C&P-24�-- <br /> B. LOCATION: '/< %, Section T_ N, R f� JK (or) W Lot# City <br /> Subdivision NamC-IVY VZt .2 nearest road, lake or landmark Blk# Village <br /> Townshi 2c//e L <br /> C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance <br /> Single family _X Duplex No. of Bedrooms v2 No. of Persons ,2— <br /> D. TYPE OF APPLIANCES: Dishwasher C YES NO Food Waste Grinder YES NO # of Bathrooms _ <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY '7-SQ 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).2�2_2) 3) a ZTotal Absorb Area .ZQ sq. ft. <br /> New X Addition Replacement *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length ,3 57 Width Depth 30il Tile Depth No. of Lines 1;2. <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land 0--- `f o� Distance from critical slope i <br /> 1, 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 Certified Soil Tester, <br /> NAME ,L,�S4,/6 //$1)e'�2 C.S.T. # �� `�-7� and other information <br /> obtained from OZ-a,7 (owner/builder). <br /> Plumber's Signature MP/MPRSW# Phone # <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 /> �00 /5t- <br /> 4 19&S 35'xi�- <br /> Do Not Write in Space Below FOR DEPARTMENT YSSE ONLY _ p <br /> Date of Application Fees Paid: State — Countp �"� ate <br /> Permit Issued/ (date) Issuing Agent Nam <br /> Inspection Yes_�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) <br /> Revised Date 6/1/76 <br />