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Plb 67 State and County State Permit # <br /> 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 Mailing Address: <br /> v � 4rn >° 5 r1C 4aKe lL? /emu /S- W o�Q <br /> B. LOCATION: JV W '/4 .SUV %, Section 4LK, T_YQ N, R_Sj (or) W Lot# -I-3—city— <br /> Subdivision Name, / nearest road, lake or landmark Blk# Village <br /> �/ q �c t of 1 4 Q Township'"( <br /> C. TYPE OF OC(AJPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family Duplex No. of Bedrooms No. of Persons_ <br /> D. TYPE OF APPLIANCES: Dishwasher YES -NO Food Waste Grinder—YES-)( # of Bathrooms <br /> Automatic Washer YES�NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7 f © Total gallons No. of tanks <br /> *Holding tank capacity Total gallons No. of tanks <br /> New Installation x Addition Replacement_ Prefab Concrete <br /> *Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ?-' 2) 3) Total Absorb Area Q 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 A p, Width Depth .9�" Tile Depth No. of Lines <br /> zi <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land Y S Ltd 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 Certilktl Spit Testgr, <br /> NAME T C.S.T. # 7 and other information <br /> obtained from P el!C'P owneAuilder). <br /> Plumber's Signature V MP/MPRSW# Phone <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> ld= <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application Fees Paid: State County Date <br /> Permit Issued/Rejected (date) _Issuing Agent Name <br /> Inspection Yes No 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 3/1/75 <br />