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, EAV.RONME rt,DN 8537*01 ,
<br /> P LB 6 7 O6 NortfiPtsconstn 7�3>0
<br /> �'. t.j State and County modlsoo. W State Permit#
<br /> r (".a� ,} Permit Application County Permit* /3/2y
<br /> i • ��,,,,+1'' for Private Domestic Sewage Systems County D�l/c
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<br /> ' 'DENOTES STATE APPROVAL REQUIRED
<br /> Date Approval iReceived from State if Required State Plan ID. #
<br /> A. OWNER OF PROPERTY Mailing Address:
<br /> Do/7 ..e .1"/k /.s<ie Ai!,V ,47 l/i s1/.7,-a/A..e, iii/c,
<br /> B. LOCATION: ,(/E y, sE '4, Section , , TS_N, RZQ E (or) W Lot# jp-`ZCity
<br /> Subdivision Name, nearest road, lake or landmark Blk# Village
<br /> S orn /Alp-- Township L4,//`1 •
<br /> C. TYPE OF OCCUP CY: 'Commercial 'Industrial 'Other (specify) rr:i 'Variance
<br /> Single fariily V Duplex No. of Bedrooms 3 No. of Persons Slj,i.,
<br /> D. SEPTIC TANK CAPACITY Ay Total gallons No. of tanks
<br /> HOLDING TANK CA ACITY Total gallons No. of tanks
<br /> Prefab con@rpte if / Poured-in-Place Steel Fiberglass Other (specify)
<br /> New Installation Y Replacement
<br /> Lift Pump Tank or Siphon Chamber Total gallons Pref b co rete Poured-in-Place Other(Specify)
<br /> E. EFFLUEN )DISPOSAL SYSTEM: Percolation Ratei��• tal Absorb Area /Ad" sq.ft.
<br /> New ✓✓ Replacement Alternate(Specify)
<br /> Seepage Tre ch: / No.of�Li,,Ft. Width Depth Tile depth(top)_No.of Trenches
<br /> Seepage Bed:, ✓ Length T• Width Dep • -p ile depth(top•- No.of Lines
<br /> Seepage Pit. Insidf dia eter� Liquid Depth o.of
<br /> Percent slope of land{ c%/ p� - s Distance from critical slope-6
<br /> WATER SUPPLY:Private ICJ Joint Cl Community❑ Municipal❑
<br /> Owners name as listed on EH 115 if other than present owner:
<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 So�il/T ter, ,i `
<br /> NAME u/a/h?r' /Iei/S1e'! C.S.T. # 9t22 and other information
<br /> obtained from I (owner/builder). // ,/ `�
<br /> Plumber's Signature nIze nfri!�i/L,!r7P0 MP/,MPRSW# r63X Phone #VI� 'yll
<br /> Plumber's Address / %I/. D.d'r yip kh :-o40"L'.c•
<br /> PLAN VIEW: - Provide sketch below of system(include direction of slope and all distances in accord with H62.20.Well loca-
<br /> tion shall be included on the sketch.Indicate or dimensiolikocationpf all wells or yte property or neighbors
<br /> property.If well has not been drilled please indicate.' : -VI
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<br /> Do Not Write in Space Below • FOR COUNTY AND STATE DEPARTMENT USE ONLY
<br /> Per of App/ca ion (date) (6- ^9 Fees Paid: Stang /S� Coun� '
<br /> Permit Issued/R�jepted (date) (0- Q -71 Issuing Agent Name
<br /> Inspection Yes_}__No State alid# Date Rec'd
<br /> 1. county .(white copy) 3. owner (green co y) DIVISION OF HEALTH,P.O.BOX 309, MADISON,WI 53701
<br /> 2. state (pink copy) 4. plumber (canary py) Revised Date 7/1/78
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