Laserfiche WebLink
Plb 67 State"and County State Permit # <br /> Permit Application County Pe it # <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 /> B. LOCATION: �'0'/4 F''/4, Section .C�, <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> } Township <br /> C. TYPE OF OCCUPANCY: *Commercia —�— *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 YESNO # of Bathrooms_ <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY rl, Yt} G 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) 3) Total Absorb Area 0 sq. ft. <br /> New Addition Replacement *Fill System <br /> Seepage Trench: No. 'Liin. Feet Width Depth Tile Depth No Trenches <br /> Seepage Bed: Length 'Y� Width Depth �� Tile Depth `� No. of Lines <br /> it <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land f 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 CerWied;Soil Tester, , <br /> NAME b 4 t ��1 n� �� 7 and other information <br /> obtained from wner/builder►. _ <br /> -- <br /> LA <br /> Plumber's Signaturel '� MP/MPRSW# ®� Phone # ��— `/jJ `/ <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> Do Not Write in Space Below FOR DEPARTMENT USE ONLY <br /> Date of Application a Fees Paid: State ' '� .Q Cou ty D,at 77 <br /> Permit Issued/Rejected (date) Issuing Agent Namefn �.rn <br /> Inspection Yes I.,---'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) Ro.,c�a.r n�ro Zit i�� <br />