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PLB 67 State and County State Permit # <br /> Permit Application County Permit # 3ff <br /> for Private Domestic Sewage Systems County Rom% <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 /> 1 0'0 V r _l�c.-ry L�C.� t-.5 <br /> B. LOCATION: tUUJ '/, tU ' /4, Section , T N, R/cc� (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village_ <br /> Township <br /> C. TYPE OF OCCUPANCY:' *Commercial *Industrial *Other (specify) *Variance <br /> Single family -' Duplex No. of Bedrooms ,? No. of Persons 2- <br /> D. SEPTIC TANK CAPACITY 7S Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E, EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. <br /> New. `� Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth�_Tile depth (top) /Z-' No. of Trenches <br /> Seepage Bed: Length Width Depth Tile depth (top) No. of Lines <br /> Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits <br /> c <br /> Percent slope of land_ .2- 22 Distance from critical slope <br /> WATER SUPPLY: Private LK Joint ❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <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 Certified Soil Tester, <br /> NAME IM f-L P_r W n C-",� "- C.S.T. # and other information <br /> obtained from ::5 ��- ,� (owner/builder). <br /> Plumber's Signature MP/Mia U# �� `= Phone # y66-- V2-Q <br /> Plumber's Address— \151 e) w/ h {' <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors <br /> property. If well has not been drilled please indicate. <br /> Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application S/ -Q/ Fees Paid: State County DatAj��. .Z if, <br /> Permit ssue Rejected (date) �{-. 6�-E`/ Issuing Agent Name ac�.It. co7 <br /> Inspection Yes No State Valid# Date 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) Revised Date 7/1/78 <br />