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T c/10 <br /> oeXiff+ i L <br /> P1_B <br /> 6 7 f State and County State Permit # <br /> i <br /> Permit Application County P�f mit # _.W.,7___ <br /> �/ for Private Domestic Sewage Systems County/-(,(Y'{"1C <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 /> tr-G r L IS r(Tr /Soh. (..V '4' L S T r Lv/ Sc • Sc./.S9 <br /> s� <br /> B. LOCATION: S'Lt.) 1/4 S 1.:) %, Section 7, T '4'ON, R )4P [' (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> Township (.9 Q 4"—X 6 4 of <br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance <br /> Single family x Duplex No. of Bedrooms No. of Persons ..J�vyi <br /> D. TYPE OF APPLIANCES: Dishasher _)S YES NO Food Waste Grinder YES YNO # of Bathrooms___1 <br /> Automatic Washer YES 'x NO ther (specify) <br /> / 0 'J <br /> E. SEPTIC TANK CAPACITY )0 DMA. 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 3) 3 Total Absorb Area 9 � sq. ft. <br /> New Addition Replacement XC *Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches_ <br /> Seepage Bed: Length Width Depth Tile Depth No. of Lines /� ti <br /> 3-- Seepage Pit: Inside diameter '7 ' Liquid Depth ' " Tile Size 7` <br /> Percent slope of land / 70 S 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 Ce fied Soil Te ter, C/ <br /> NAME d(--J-,c y-�- ( h r C.S.T. # 7 3 7 and other information <br /> obtained from frq,- ( / t►/+ I e S 0 (owner/builder). , <br /> Plumber's Signature 'i/i ct C0MP/MPRSW# © 3 A y Phone # Y66 V1 S' 7 <br /> Plumber's Address s . \...0-4;1..e, q f'Y ?. <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> t*Np, <br /> d '1:1 <br /> I 7 <br /> V/ I <br /> v. <br /> -1. / ) P s / • 0r ��' �' ' <br /> tis t, 7 o 4,0-7'' , IV (;) <br /> ,,,riI <br /> I 7' w s f cr S 1,-ovk . l ill ci 6 ef. °('/I. <br /> di L, ° fry, <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application b- p�- -7,3 Fees Paid: State `'"—" Con _ate 2' 3 , <br /> Permit Issued/ td (date). ,R---7s _Issuing Agent Name 4,c)�it_ '_o/rt if <br /> Inspection Yes V No Valid# / <Beate 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 6/1/76 <br />