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PLB67 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 /> 5 7- -r;QVTC.y/N ,37/ 466.Pl i?-iTfF S7 3r <br /> B. LOCATION: '/4 k, '/4, Section A5 TSLON, R__045—t (or) W Lot# _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> ' / Township __ �} <br /> VQfCS(?A( <br /> IKtiJG !-4ilrc- of VOCM� Vt,&_ 4 <br /> C. TYPE OF OCCUPANCY: *Commercial 'Industrial *Other (specify) *Variance <br /> Single family >4, Duplex No. of Bedrooms P�_ No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher YES _,NO Food Waste Grinder_YES ! NO # of Bathrooms—L7Z_ <br /> Automatic Washer YES _ANO Other (specify) <br /> E. SEPTIC TANK CAPACITY 7.6-0 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_ K Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1► _ 2)x_3) Total Absorb Area 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 AG Width h_Depth—2rTile Depth No. of Lines <br /> Seepage Pit: Inside diameter ' Liquid Depth Tile Size <br /> Percent slope of land 2 Q 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 Certified Soil Tester, A� l <br /> NAME n FiFJ2 T f"� /V C.S.T. # ­X91--11. and other information <br /> obtained fromti� lIl�YV }ewraeilhuiIder). <br /> Plumber's Snature ig �� MP/MPRSW# 3e2 Phone # Zyq33dCi <br /> Plumber's Address 7»r�2�/ C# !lT/ 5'rf573l� <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> j t1, <br /> z3` <br /> got <br /> 4 <br /> Lu� <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application 5_-/;2-74Z Fees Paid: StateA0 � _Cogn ate <br /> Permit Issued/R (date) ?�'��— 70 Issuing Agent Nam <br /> Inspection Yes_k!!1*_No Valid# Date Recd <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 6/11/76 <br />