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<br /> �`� j State and County n 1978 State Permit # /y 5�
<br /> OCT _
<br /> (�j Permit Application County Permit # / ���.
<br /> for Private Domestic Sewage Systems County —,UAw�
<br /> D" ':;,,_I��'y Envirc rrmenta
<br /> TES STATE APPROVAL REQUIRED ii r.'i:� Depcirfinent
<br /> Approval Received from State if Required _ State Plan I.D. #
<br /> OWNER OF PROPERTY Mailing Address:
<br /> K�/4`c5 F,ocz 01-04-? B".• I e y �w C. //6-6 w • rrl 9 ze...) 57:
<br /> S a 4/&.e.rai.ree LcJ 7 c 5-3 5-Pc
<br /> B. LOCATION: /frto '/<5 'h, Section j, T 2 N, R// E (or) 411 Lot# .3 f City
<br /> Subdivision Name, nearest road, lake or landmark Blk# Village
<br /> ,� Township --,?, /317,2
<br /> /74'/F7/F L>/&W f,(d,4/.
<br /> C. TYPE OF OCCUPANOY: `Commercial "Industrial "Other (specify) "Variance
<br /> Single family X Duplex No. of Bedrooms 3 No. of Persons -
<br /> D. TYPE OF APPLIANCES: Dishwasher YES .X NO Food Waste Grinder X YES NO # of Bathrooms
<br /> Automatic Washer X YES NO Other ((specify)
<br /> E. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks /
<br /> 'Holding tank capacity Total gallons No. of tanks
<br /> New Installation X. Addition Replacement Prefab Concrete X
<br /> 'Poured in Place Steel Other (specify) ;
<br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)3 V 2) `/O 3) 37 Total Absorb Area/.2,O0 sq. _ft. -
<br /> New X Addition Replacement 'Fill System
<br /> Seepage Trench: No. Lin. Feet Wid 1h � _D
<br /> ' iDepth Tile Depth No. of Trenches
<br /> Seepage Bed: ' Length Ff O Width _Dep h Tile Depth) No. of Lines .3 a `
<br /> Seepage Pit: . Inside diameter Liqui• Depth ..`' Tile Size' y,.
<br /> Percent slope of land 0 Distance from critical slope
<br /> I, the undersigned, do hereby certify that the in ormation I have reported is in accord *with. Section H62.20, 3;
<br /> Wisconsin. Administrative Code, and that I have sired the effluent disposal system from the EH-115 prepared
<br /> by the Certified Soil Tester,
<br /> NAME 24 2 -,r[-- S, 24.4.).74...," C.S.T. # SS- /OS and other information
<br /> obtained from -Ass '.9dI ore r 134: 1./..., $.v (owner/builder . '' '
<br /> Phone #aS$ —
<br /> Plumber's Signature �������_� MP/MPRSW# ���� —0,379
<br /> Plumber's Address i13 't5 2 `--) •r 04 it 7%7,4_4 R7/, 07 Lb-e*Ver''t 4414s s'35"XS
<br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
<br /> H62.20, including well). ' 1\- =+m e,i
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<br /> Do Not Write in Space Below- FOR DEPARTMENT USE ONLY
<br /> Date of Application ,11-Z-7? Paid: State /O Coun y Fr15 Date
<br /> Permit Issued/Rejected (date) //-t' -7C" Issuing Agent Name [ -t_
<br /> Inspection Yes No
<br /> Valid# Date Rec'd
<br /> 1. county (white copy) 3. owner (green', copy) DIV N OF HEALTH, P.O. BOX 309, MADISON,WI 53701
<br /> 2. state (pink copy) 4. plumber (canary copy) ' Revised Date.611/76'
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