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PLB 6 State and County State Permit # <br /> Permit Application County Per ' # <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 /> E - V.4ja4ktcj� <br /> B. LOCATION: '/< Y<, Section j'- TtZJ2N, R (or) W Lot# _City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> � R it ( Township trj¢��C- Cjr,/ <br /> C. TYPE OF OCCUPANCY: `Commercial `Industrial `Other (specify) `Variance <br /> Single family � Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY 7!M 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 K Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate-----;7Total Absorb Area sq.ft. <br /> New— >kS Replacement Alternate (Specify) <br /> Seepage Trench: No. of Lineal Ft. Width Depth—Ti le depth (top) No.of Trenches <br /> Seepage Bed:— 7�- Length a Width1_Depth�_Tile depth (top)�_No.of Lines <br /> Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits <br /> Percent slope of land �O� Distance from critical slope <br /> WATER SUPPLY: Private K Joint ❑ Community ❑ Municipal ❑ <br /> Owners name as listed on EH 115 if other than present owner: <br /> 1, 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 ®Nf�l.p i=. }�/ q/ ,—e T C.S.T. # — and other information <br /> obtained from �i (Q/1� (.owner ui er . <br /> Plumber's Signature MP/MPRSW# =3072-- Phone <br /> Plumber's Address— V;9!R-V s-ye' 30 <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 /> 22© <br /> 7�r <br /> A L <br /> 3e` <br /> 2� • <br /> 2zy� IL a <br /> Do Not Write in SpaceB ow - OR COUNTY AND STATS DEPARTMENT USE ONLY <br /> Date of A lication Fees Paid: State //�. County ate <br /> Permit ssued Iejectt dat Issuing Agent Name i <br /> Inspection Yes to No State Valid# ate 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) Revised Date 7/1/78 <br />