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<br /> Plb 67 . , •.,111,
<br /> State and County State Permit*
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<br /> .." I Permit Application County Permit*
<br /> 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
<br /> Mailing Address:
<br /> VIII6allA- RIITS IQ A-It 1 ti oit.).4-
<br /> B. LOCATION: ArS",Z /tic Y. SE '4, Section 3', T I., N, R '14 E (or) W Lot* City
<br /> Subdivision Name, nearest road, lake or landmark Blk# Village
<br /> Township //ENDA/of.
<br /> Co. )s,FIR 0 F ao R Cji -r RD ,e-- 5idnise-r AD.
<br /> C. TYPE OF OCCUPANCY: •Commercial •Industrial 'Other (specify) Variance
<br /> Single family )(' Duplex No. of Bedrooms .3 No. of Persons 471
<br /> D. TYPE OF APPLIANCES: Dishwasher X YES NO Food Waste Grinder X YES NO * of Bathrooms Hi
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<br /> Automatic Washer ,eit YES NO Other (specify)
<br /> E. SEPTIC TANK CAPACITY MOO Total gallons No. of tanks f
<br /> "Holding tank capacity Total gallons No. of tanks
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<br /> 9•-• New Installation X Addition Replacement Prefab Concrete X
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<br /> "Poured in Place Steel Other (specify)
<br />• - F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 5- 2) ,/,P 3),S-7 rTotal Absorb Area 57D0 sq. ft.
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<br /> New/1C Addition Replacement 'Fill System
<br /> Seepage Trench: No Lin. Feet Width Depth Tile Depth No of Trenches—
<br /> Seepage Bed: Length Se Width ler/ Depth 9p' Tile Depth 36 " No of Lines A.
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<br /> Seepage Pit: Inside diameter Liquid Depth Tile Size •"/
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<br /> Percent slope of land AP-0--
<br /> Distance from critical slope --
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<br /> I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
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<br /> Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH 1)5 prepared
<br /> by the Certified Soil Tester,
<br /> NAME /9/9/(M-1../) iii. 44,10,41 44,—p C.S.T. * -51S— 7O1 and other information
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<br /> obtained from .1)44. A k viD9A1 AT'Arr (9MIllbuilder).
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<br /> Plumber's Signature Aipmigivsgoito S7 / Phone
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<br /> PLAN VIEW: Provide sketch below of system (include directi•• . slo. • all distances in accord 'th -.41114
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<br /> H62.20, including well).
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<br /> Do Not Write in Space Below - FOR DEPARTMENT USE gnyu..5- .6,903
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<br /> Data of Application Z -9- - Fees Paid: State J- P- tounty - yap
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<br /> Permit Itsued/Rejected (date) (,-•-,4 -1.5- Issuing Agent Name e}.14,j ra 4:1-44,444/1
<br /> Inspection Yes No Valid* Date Reed
<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 3/1/75 j •
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