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<br /> ' Plb 67 Lr j MADt.--, State and County State Permit # • 95 ZW 4
<br /> i a'0'- Ji Permit Application • County Permit # S 4461 7
<br /> for Private Domestic Sewage Systems County 1)?2 /L€
<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 /> /th'e r St /E17e S'. P"/Le- J� %/�'G A�_P J`1n,.o J i,�x GtJ/ 5 6 5-3 7 J /
<br /> B. LOCATION: /? W 14 $e 1/a, Section 3v , T 7 N, R .6) E (44--W Lot#l /5 City
<br /> Subdivision Name, nearest road, lake or landmark Blk# Village
<br /> dh/EAo43 tvOd D Township M/',pt. TOA/
<br /> C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
<br /> Single family > Duplex No. of Bedrooms rigeJQE No. of Persons ,
<br /> D. TYPE OF APPLIANCES: Dishwasher ,)C YES NO Food Waste Grinder >YES NO # of Bathrooms 'a•—
<br /> Automatic Washer .)( YES NO Other (specify)
<br /> E. SEPTIC TANK CAPACITY lec (_ Total gallons No. of tanks /
<br /> *Holding tank capacity Total gallons No. of tanks
<br /> New Installation I,/' Addition Replacement Prefab Concrete L--------
<br /> *Poured in Place Steel Other (specify)
<br /> F. EFFLUENT OSAL SYSTEM: Percolation Rate 1). C 2) 4 3) 9-4-Total Absorb Area Q () sq. ft.
<br /> New ddition Replacement • *Fill System
<br /> Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
<br /> Seepage Bed: Length: Width i y` Depth Ca" Tile Depth 'y b" No. of Lines
<br /> Seepage Pit: Inside diameter Liquid Depth Tile Size r
<br /> Percent slope of land ,r,.3-5)4; Distance from critical slope C: '7"'
<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 Tester,
<br /> NAME if • tr , C.S.T. # /L e a and other information
<br /> obtained from ♦ f owner wilder).
<br /> Plumber's Signature VI, �r PRSW# 3 ' 7 Phone #. 7( —la 7/
<br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
<br /> H62.20, including well).
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<br /> Do Not Write in Space Below - FOR DEPARTMENT USE ONLY �(O a"l�'�'',?,..
<br /> Date of Application —/-- 76) FF -^ate /— County •
<br /> ,oZ o-- Date
<br /> Permit Issued/Rejected (date) ,6—/1 Agent Name ‘,146-2.":14—b E Y.rL 'i.
<br /> "tion Yes No Date Rec'd
<br /> HEALTH, P.O. °^ 4.,'•
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