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P L B 67 State and County State Per <br /> # <br /> Permit Application County Per 3 # <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 /> lrf11#6�Q Sc#WAP-7ZAow c�7 e6 F�10,4Z 6 /b(� <br /> B. LOCATION: �rr % NE '/<, Section ;/_, T/O N, R -C— f ) Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township JIC07r <br /> C. TYPE OF OCCUPANCY: 'Commercial "Industrial 'Other (specify) `Variance <br /> Single family X Duplex No. of Bedrooms No. of Persons <br /> D. SEPTIC TANK CAPACITY 4?rO0 Total gallons No. of tanks / <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation X Replacement <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete_Poured-in-PlaceOther (Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Areasq.ft. <br /> NewX Replacement Alternate (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width Depth—Ti le depth (top) No.of Trenches <br /> Seepage Bed:_ 7—Length__q_j _WidthZ&7' Depth uZ' Tile depth (top) JUD No.of Lines &7— <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 19 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 CiE C/4 C.S.T. # 5. - '5i 8cl and other information <br /> obtained from A .S'GN!atATZ<ow owner/builder . <br /> Plumber's Signature 01 MF/MPRSW# �d� Phone <br /> Plumber's Address ,P?'. 2- S'//E'1L 44kE' .5-VII7,F <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 /> i <br /> lob I (27/ <br /> /o 7 Sr;c4- <br /> A` <br /> Do Not Write in Space - R CO NTY AND STAT&PePARTMENT USE ONLY �o <br /> Date of tion Fe id: State Coun y Dat <br /> Permit sued/ ejected at Issuing Agent Name <br /> Inspection Yes No State 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 7/1/78 <br />