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PLB 67 <br /> State and County State Permit # � <br /> 0 Permit Application County Permit # <br /> for Private Domestic Sewage Systems County <br /> `DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan I.D. # <br /> A. OWNER OF PROPERTY �1 Mailing Address: <br /> / <br /> B. LOCATION: 14 wr % tV k) /a, Section Tom(_N, R,4V_ It (or) W ot# 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 i/ Duplex No. of Bedrooms .:2 No. of Persons_ <br /> D. SEPTIC TANK CAPACITY 2 A-._6 Total gallons No. of tanks <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Poured-in-Place Steel I-- Fiberglass Other (specify) <br /> Prefab concrete 9 <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 30 sq.ft. <br /> New 4-- Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth—Ti le depth (top) No.of Trenches <br /> Seepage Bed: r---- Length (. 4' Width 15—' Depth D. ' Tile depth (top)—,Z No. of Lines ✓ <br /> Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits <br /> Percent slope of land /) `,) Distance from critical slope 0 <br /> WATER SUPPLY: Private X 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 VA cr-- Z ( n L. �r C.S.T. # <- -_ :.7/0 and other information <br /> obtained fro (owner/builder). <br /> Plumber's Signature v7 MP/ # <br /> Plumber's Address— <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 A lication �� �/ Fees Paid: State 1� County Z( Dated �� 1/ / 9��/ <br /> Permit ssue Rejected (date) 2F/ Issuing Agent Name'' <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) <br /> Revised Date 7/1/78 <br />