Laserfiche WebLink
Aug. 13. 2009 2:39PM No. 1127 P. 1 <br /> rts....��-117.0�7 R��:+ CONSIN 53706 <br /> F Lb)/ •;r, . " 'State and County State Permit# <br /> Permit Application _cp{VSO County P°rmlt# <br /> for Private Domestic Sewage County /2;4 Cr <br /> 'DENOTES STATE APPROVAL REQUIRED '( i ti•+'6 <br /> Date Approval Received from State if Required —- 'State Plan I <br /> A. OWNER OF PROPERTY t <br /> (ern v. 1 Me G 000 s C etp%0% <br /> MI Woe..., -, .,kc. iy <br /> B. LOCATION! . E X li) X. iSection 3 D, T,�_N. RL E (or) W Lot# City <br /> Subdivision Name, 1'e.11?De lea eenst road, lake or landmark 8tkat Village <br /> Cs •S�i q Township I�vt42etr�/ <br /> _% 9 Mute <br /> C. TYPE OF • U-A' '. • erc)al Industrial ether spec 1 Variance <br /> Single family t.,4 Duplex No. of Bedrooms 4 No. of Persons 3 <br /> D. TYPE OF APPLIANCES: Dishwasher YES rX NO Food Waste Grinder YESi'NO * of Bathrooms <br /> Automatic Washer a YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY (3 O a Total galpllofs of tanks O v Y <br /> 'Holding tank capacity a eo a 1bial gsallpns 51' "Cf amts �'^ e <br /> New tnstalletion Addition Replacement Prefab Concrete s-f' <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 1 2) 0 31 40 Total Absorb Area sq. ft. <br /> New Addition_Replacement ✓$' 'F111 System <br /> Seepage Trench: No. Lint Feet Width Depth Depth No. of Trenches <br /> Seepage Bed: Length 7 S Width /s Depth 3e - 'file oepth .1 1g. No. of Lines 3 , <br /> Seepage Pit: Inside diameter Liquid Oepih Tile Size 4 <br /> Percent slope of land_ 5'.. Distance from Critical slope?.2O ' <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 Fl Tgoe r, <br /> NAME Ro e,-1- C , F rA _L S C.S.T. * /SS / and other information <br /> obtained from ^ ( ,a - C . (owner/builder). <br /> Plumber's Signature i-(441' MP # 3483 Phone 3-V S 3 / <br /> Plumber's Address %fk' 'Il111UNJ!fVtr. . AMC • a. <br /> PLAN VIEW; Provide sketch below of system (include direction of elope and all distances In accord with <br /> of H , including weep. <br /> I <br /> • . k70o r,:e. <br /> , . . i._ . .. . , <br /> 7b0' ^� N1 <br /> Hp� 'R . <br /> !1 i <br /> 40 a .40 r 1 1 • <br /> S.Y 1300 1 .. --, • i <br /> d`~� 1. <br /> • <br /> 1J <br /> • o. 1 � ----d P.1-ii .....y .a . <br /> �a rte.•�b OP/ .4.y. Q3 <br /> In <br /> o Apple: fry 4: � s. • <br /> .pret4, eosf. . . .6 4.45.1C f" s4° i <br /> I <br /> • <br /> •Do 'Net Write in Spece Below • FOR DEPARTMENT USE ONLY G Da <br /> Date of Application /O•.2ff•96, Fees Paid: State - <br /> ^ County <br /> Permit limed/Rejected (date) l0-�5-Z. Issuing Agent Name <br /> Inspection Yes No • Valid# Otte Recd <br /> ►1. county (white copy) 3. owner (preen copy) DIVISION OF WEALTH,P.O.BOX 309.MADISON,WI 63701 <br /> 1'd 1599 E179 909 oll smite/tins puei uou0 d9V:Z0 60 91 6nV <br />