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r' ' <br /> ' gA,P1F CUv^.:'nRnpRTM�1` <br /> ., • •• ' Ys 1',., SSri4 5370° <br /> • r �i State and County MAD I vl"CONState Permit# 3 2 6' <br /> cti:a4 J Permit Application County P,,q rmit# S p0 <br /> for Private Domestic Sewage Systems County(Jane, <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 /> _.::ri __.:..nelnn (E!;9 11,:..tcl :ir La. , , _. is-r'a, ,i. 5'.711 <br /> B. LOCATION: NE 14 Se ''4, Section ,, T=N, R f; € (or) W Lot# _ 17 City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> '7,1-erry 11111 Township 1191'i IL:fiQld <br /> C. TYPE OF OCCUPANCY: 'Commercial 'Industrial 'Other (specify) `Variance <br /> Single family Duplex No. of Bedrooms <+ No. of Persons 5 <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder X YES NO # of Bathrooms_ <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 1 7n0 Total gallons No. of tanks 1 <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) 11- 2) 20 3) 22, Total Absorb Area 1000 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 :' i,1 Width 17' Depth -,Tile Depth No. of Lines 2 <br /> Seepage Pit: Inside diameter Liquid De the 3-44 r Tile Size 1;" <br /> Percent slope of land 10 - 1/, Distance from critical slope ) 20' <br /> 1 o. -77.o <br /> I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, � .4." <br /> Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared <br /> by the Certified Soil Tester, <br /> NAME J c, r nh A. :.,: .nhol? C.S.T. # C.39 and other information <br /> obtained from A i . • Alf (owner/builder). <br /> Plumber's Si ature‘MMir � <br /> i 2963 Phone # C26-21303 <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> • <br /> Col ' <br /> 4ori'n i <br /> F - <br /> f I <br /> � 1 <br /> I i <br /> 1 0 <br /> • <br /> ..1_ . j <br /> i <br /> 1 i i <br /> -- . i _�- _ <br /> , f V <br /> j_ _'-._ -� - ;. _ /+1►s�i 1 -r }._. _ <br /> '• 1 �. j a` r i <br /> i <br /> "� ,... i. <br /> _ <br /> i <br /> 1\ 1 - - <br /> _ I <br /> 1 + -1 J <br /> I <br /> 1 <br /> + 4 L i•. i ■ <br /> i 1 <br /> Do Not Write in 'Sp :slow _ FOR D ' •RTME ' USE ONLY <br /> Date of Application - )[•7(.. Fees Paid: State - County D - Date <br /> Permit Issued/Reject (date) 3-_.:2 V-76• Issuing gent Name A-2,-,..6..,„ C_Qcw i <br /> Inspection Yes N• Valid# (( Date Rec'd <br /> 1. county (white copy) . • green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 <br /> 2. state (pink copy) 4. plumber (canary copy) Revised Date 3/1/75 <br />