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VANE i-'_._.., ; PUBLIC HEALTH DE''.. • <br /> IENVIF:'NrA`i:l' A'- H ALTIt t OlbiSic:r{ <br /> n ry n 3 <br /> PLB 67 <br /> _ I0 �F::tE va-sn <br /> /,:��'�;'�! State and County S€ate Permit,;41x <br /> c�g!%� 1 Permit Application County Permit_ X43 <br /> V•'x- 3' for Private Domestic Sewage Systems County '''" <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required - State Plan ID. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> JOines --5.• r0, . N 1346 leur/e'.n6S S r rn4-.0/so Ai tr.1/s . <br /> B. LOCATION: Sul %SE ''/., Section J/ , T Sr N, R /1 E P■W Lot# City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> C5, 73 Q Township0G/V/ /4f <br /> C. TYPE OF OCCUPANCY: *Commercial 'Industrial a 'Other (specify) `Variance <br /> Single family X .3 <br /> Duplex No. of Bedrooms No. of Persons - <br /> D. SEPTIC TANK CAPACITY /ODO Total gallons No. of tanks D AIE RECEIVED <br /> HOLDING TANK CAPACITY Total gallons No. of tanks <br /> Prefab concrete X Poured-in-Place Steel Fiberglass OthesE(Fpe1ifq) <br /> New Installation X Replacement, <br /> Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Plone,.0 y(8pe h fl entPI <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate-75+32 2Total Absorb Area SCl q. . <br /> New X Replacement Alternate(Specify) <br /> Seepage Trench: No.of Lineal Ft. WidthFDepth Tile depth(jop).___No.of Trenches <br /> Seepage Bed: X Length 47 / Width 24 Depth 36.-fa file depth(top). jZ No.of Lines T <br /> Seepage Pit: Ins, diameter Liquid Depth No.of Seepage Pits <br /> / <br /> Percent slope of land + Distance from critical slope > 2. <br /> WATER SUPPLY:Private rgl Joint❑ Community❑ Mu,icipal❑ <br /> Owners name as listed on EH 115 if other than present owner: 4 A' NQ R77-0 N <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 TesteL <br /> NAME :10/i1.FS /C. )p hKL/A/6 C.S.T. # and and other information <br /> obtained from - O (owner/builder). <br /> Plumber's Signature G_ ' _ _._ _i w# £6 00 Phone #?S/-409 t <br /> Plumber's Addresses 'i' E PAPS J D• /27e.,�C -4,U d , LAI/,S. C3,S=ln <br /> PLAN VIEW: Provide sketch belo t 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 indicatg,_,r.i-74-943" g,f 010r OP id <br /> ' , <br /> . - ' , J x �i-- - <br /> i <br /> -1 1_ _ - - - - <br /> _1-_ <br /> -'- t <br /> _ � . - !iO D� i• p - ._ .L_- - <br /> __-- <br /> • r_ __ t- ----I L I <br /> t __ <br /> erPrt/G 7'4, /C! TO FJi6 t '4s C i ; ' --I- - I `` <br /> 1 I l <br /> . <br /> %!�--; 1 /} ,' !.- ' 1lr,- j L/ Y__ i ! -1' �_ i -r !- <br /> - I ' I I r <br /> i 1u <br /> O 1 !� -1----1-4(- 7 ST • I <br /> --- <br /> I 1 I i ,_i I <br /> I ; --•-1 1. ' 1. _� <br /> -_ I__ __ ,_._ t-. __�._-_ �_._� _._— 1 __ , __Ir__ -_ t -_, ,� _ _--_ _._• <br /> -4-` -- F—--- -_ ---; ._Y.. _1- i 1- -t-.,i_-' -_ ._ _ IN. r_. __i _ 1 -._. <br /> l �_ <br /> r <br /> I ' <br /> ( ~, <br /> Do Not Write in .ace eBBelow - FOR COUNTY AND STATE DEPARTMENT USE ONLY <br /> Date of Application et 7-OS-71 Fees Paid: State /.512° Coun IR Permit Issued/Rejected (date) `r-ri PS' 77 Issuing Agent Name %,/4 . l <br /> Inspection Yes No State 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) <br /> Revised Date 7/1/78 <br />