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I - DANE COUNTY <br /> ti ENVIRON?.+Eti t.l. i{`.A?.TH DEPARTMENT <br /> 1202 l OR T N?ORT DRIVE 33 9 <br /> • Rib'•67,-' .r t, MADISON,W ISCO�tSN a��7Gbiunty State Permit# <br /> �kia,11 Permit Application County Permit# &MN <br /> for Private Domestic Sewage Systems County Da oe <br /> • <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> Date Approval Received from State if Required State Plan ID. # <br /> A. OWNER OF PROPERTY Mailing Address: <br /> �aL /-i1''i Ace W )01,1.4.} e'I`s•`- u.ee.✓ <br /> B. LOCATION: 11/u1'G fE'h. Section , , T 0 N, R /0 E (or) W Lot# City <br /> Subdivision N e, nearest road, lake or landmark Blk# Village //��" <br /> y /J- 6_3 Township ,6.�r1 <br /> C. TYPE F OCCUPANCY: `Commercial 'Industrial ' 'Other (specify) /&,f. `Variance <br /> r-.--"------ <br /> - / <br /> Single family Y <br /> Duplex No. of Bedrooms No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher 4,7YES NO Food Waste Grinder L.---YES NO * of Bathrooms -- <br /> Automatip Washer ,/YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY 1, 6/01 Total gallons No. of tanks_i_- <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation t -/ Addition Replacement Prefab Concrete c/ <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) /Z 2) /,63) /d Total Absorb Area /Od/ sq. ft. <br /> New c/Addition Replacement 'Fill System <br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length IP. Width .2 it Depth ,'-(e Tile Depth lL/ No. of Lines y <br /> " <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size <br /> Percent slope of land I °Id Distance from critical slope 5 0 <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 Teste, p � <br /> NAME /A ,. i/ _ . C.S.T. # /G1" - and other information <br /> obtained from � L_ /'�sfIPe� P' (owner/builder). '/ <br /> Plumber's Signature V ' , ''I / MP/MPRSW# Ie2 7 Phone #17J(--c 'VV <br /> PLAN ')(IOW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> N H62.20, including well). /23-4/ <br /> 1 idilli . 1 i , ., i i ; , ; , i . i <br /> t r I + r <br /> t <br /> I ' ' <br /> " <br /> 1d ! ■ I I r <br /> �' iliel.- 1.- O!7/! -Is! 2,, _i_ <br /> .- I I <br /> -1- <br /> I I I <br /> i , 111 <br /> - <br /> 1 r I__ <br /> FF <br /> ' I 1 <br /> I I I i j i 1 I <br /> i I I <br /> 1 _ <br /> ', ! t 4 j } - �- _i _ -, <br /> I _ <br /> 1 <br /> i I I 1 I ' 1 t <br /> i <br /> I r'_- I I 4, F-t_ �- t i l f I { M _vol. I <br /> -- F = - �.— <br /> { <br /> , i I I t t <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application I-/, -7G Fees Paid: State /- County o- Date <br /> Permit Issued/Rejected (date) /--G-7(o Issuing Agent Name 61-1.4...-s-1. e. h.u',...fi-cam <br /> _ Inspection Yes No Valid# Date Rec'd <br /> 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 63701 <br /> 2. state (pink,copy) 4. plumber (canary copy) <br /> Revised Date 3/1/75 <br />