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• j 1 S E DANE CO13NTY L KAlI"DEPT. <br /> • ErtV1R411h�ENTA Ccuniy p1dg. <br /> (.� ,• .. 313 .rCtt ns�n 53709 <br /> f L B 6 v;. Room p <br /> �•� 1 State and County Mac{isen, V`,lsco State Permit# 1� 6 q <br /> n � Permit Application County Permit# __in ill Ip' <br /> For Private Domestic Sewage Systems County _ Jaio <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 /> 2g 'C 11J //0 l? f / 0x.6-Go_A✓ <br /> B. LOCATION: 4(/C,/yVt/d,/'/., Section /,,''`.,, T S N. R /4 E (or) W Lot# 'y City <br /> Subdivision Name, nearest road, lake or landmark Blk# Village <br /> 014-u �•' Township x/ <br /> J /l `1 ao r� arc i AV. • 4,077.A/V <br /> C. TYPE OF OCCUPANCY: *Commercial --"industrial 'Other (specify) Variance <br /> Single family _ Duplex No. of Bedrooms No. of Persons_5S/EC, <br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms,L' <br /> Automatic Washer YES NO Other (specify) <br /> E. SEPTIC TANK CAPACITY / <br /> /(X�G Total gallons No, of tanks <br /> `Holding tank capacity Total gallons No. of tanks _ <br /> New Installation L/ Addition Replacement Prefab Concrete e....----- <br /> 'Poured in Place Steel Other (specify) <br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)Z 2) 3 3) 3 Total Absorb Area Q'‘i.) sq. ft. <br /> New /f Addition Replacement "Fill System <br /> Seepage Trench: No, Lin. Feet Width Depth Tile Depth No. of Trenches <br /> Seepage Bed: Length$01 Width 12." Depth qJ JOTile Depth_'/- 3?.!"No. of Lines '2_ <br /> Seepage Pit: Inside diameter Liquid Depth Tile Size V" <br /> Percent slope of land 2....aD/9 Distance from critical slope '7.20' <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 NAME c)Or eV /q ,,44 /t '/964:2_,......_C.S.T. # G l <br /> and other information <br /> obtained from r • - a__ . -c) (owner/builder). <br /> Plumber's Signature 1 ,.. ,. � r • i MP/MPRSW# ;�'Y.'Y Phone #g;2/-42.4) 3 <br /> Plumber's Address /r-s- % • %1 =, <br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with <br /> H62.20, including well). <br /> led OS‘—v4'T /'o,9CJ • <br /> 4/A7"E,e /n/ fia o.vT <br /> FROM -3.-Ohs/ i hiELG . <br /> / <br /> ..lt /e t /r CYARA�6 E- as x <br /> . 4 a6 g E , <br /> i ,yo /s- / $T Pro Ptt �4n, •s <br /> :- ._ <br /> / Z1�,i�NN .F/z j <br /> L C A-Tiok0 TO <br /> f. P2/2Y to' I EAST of 66,e66 <br /> I <br /> . i l 7/0 k-1/b r °.1-Gf.4, oil /es, <br /> Do 1t Write in Space Below • FOR DEPARTMENT USE ONLY <br /> Data Application ""?..- .S--7 7 Fees Paid: State )O ' County . 0�J Date <br /> Permit•sued/Rejected (date) '7 a,S-77 Issuing Agent Name I . _ • elc.t,`)�, <br /> lnspectitYes No Valid# Date Rec'd .. <br /> 1 coum,... :._ ,._ .._.._.. -.. ..,... --- ..._._•_. <br />