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DANt w r-,gRFMEilL1 I <br /> ENVIRONMEIJ'�L 'ED` <br /> .... . , <br /> 1202 Nye- d <br /> P L.B6 MADISON. W -" <br /> r � State and County State Permit# f 3 <br /> ARI' Permit Application County Permit# 9/8 4' <br /> for Private Domestic Sewage Systems County 0 a/9€ <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 /> /LOCATION: Rare,zr.+ 3 (C0/uNt is 1•t'/sc S�S90 <br /> B. _S�'' '4 Sr 'h, Section 2, T 9 N, R l E <br /> 9 (or) W Lot# City_ <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> a <br /> VV <br /> Township [r,jcyo <br /> frees m ea r el v ON <br /> C. TYPE F OCCUPANCY: 'Commercial 'Industrial "Other (specify) `Variance <br /> Single family ✓ Duplex No. of Bedrooms ? No. of Persons <br /> D. TYPE OF APPLIANCES: Dishwasher AYES NO Food Waste Grinder L- SNO # of Bathrooms! <br /> Automatic Washed---YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY /DOO Total gallons No. of tanks <br /> 'Holding tank capacity Total gallons No. of tanks <br /> New Installation Addition Replacement_ Prefab Concrete / — <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 113V 2) 9r3) yrfotal Absorb Area 970 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 /b._ Width -Y Depth p'Tile Depth 3,w" No. of Lines y <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size y <br /> Percent slope of land 27 W>d E Distance from critical slope G `� <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 C rtg�jed Soil Tester, ,r, <br /> NAME V Am e r I (0c)/). ` /A9 C.S.T. # 757-- <br /> 5 and other information <br /> obtained from / (plyperLbuilder). p� <br /> Plumber's Signature MP/MPRSW# S'C Pk' Phone #Cr�7- 3"t? <br /> Plumber's Address 7 /?1(,5- y[/ AlArAk, S? .Cu., fir,.,/'/ 'e <br /> PLAN VIEW: Provide sketch below of system (include direction of slope .and all distances in accord wit <br /> H62.20, including well). <br /> ei <br /> '' <br /> 4, / / <br /> 0-eel-e <br /> s / <br /> v <br /> _52 ,y �QN¢ 444 <br /> 5,2 ,4/ use 7�arot'kf " <br /> 9 <br /> /a' (eye 466"747"').P` <br /> it / 2 2 3 ' <br /> e ' eg 97/(rt°e N <br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY <br /> Date of Application 9-/ct-2(e Fees Paid: State /— County 'O— Date <br /> Permit Issued/Rejected (date) 9-/ -1(. Issuing Agent Name (s, • ....., <br /> Inspection Yes No Valid# Date Recd <br /> kite copy) 3. owner (green copy) DIVISI OF HEALTH,P.O.BOX 309 M <br /> canary copy) <br />