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PLB67 State and County State Permit # <br /> Permit Application County Per 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 /> ') qvl I ��� � �S 6 cN � V00 W 'r 65rpr (tir� C sy�?3 <br /> B. LOCATION: 1 '7141 VL'- %, Section a , T_QN, R_ b Q7 (or) W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> TC <br /> h/ h T 6 , < 0 ft� Township 0 0i 4 t n <br /> -1111 <br /> C. TYPE OF OCCUPANCY: Commercial Industrial *Other (specify) *Variance <br /> Single family X Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher X YES NO Food Waste GrinderYESNO # of Bathrooms <br /> Automatic Washer x YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY ol- Total gallons No. of tanks <br /> *Holding tankcapacit 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) q 2) 3) Total Absorb Area tr 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 J6 � Width Depth a Tile Depth I a No. of Lines 3 r <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> � r <br /> Percent slope of land if) 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 Cert i ' dit Teste , <br /> NAME n f C.S.T. and other information <br /> obtained from r build <br /> Plumber's Signature Opt MP/MPRSW# C 1G:/ Phone <br /> Plumber's Address , 4Zf <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> ie <br /> 3za <br /> d�G <br /> ��4 c <br /> Do Not Write in Space Below - FOR DEPARTMENT U E ONLY <br /> Date of Application — _Fees Paid: State 6 Cou ty to <br /> 1C7 <br /> Permit Issuedl9sjeEftd (date) y —y -17Z Issuing Agent Name <br /> Inspection Yes L�440 Valid# to 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 6/1/76 <br />