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<br /> _ `;S'ii - State and County Ro rsClt, Wisconsin State Permit# i O C'6_!
<br /> V>�j• Permit Application County Permit/#\,_�,�O��_��_._
<br /> for Private Domestic Sewage Systems County _.........._ st?U -—._
<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 /> Ocvo- 4 Mig 0 I? /z / o,eGGo.,v .
<br /> B. LOCATION: 4z/61:4//2_,V_%, Section esy,'_, T S N, R /6 E (or) W Lot# Q9_._City___
<br /> ._„__
<br /> Subdivision Name, nearest road, lake or landmark Blk# Village_,_
<br /> 0#4-r Township__
<br /> Y f�fl, do,s-- - a6---c 7- AV urca✓p
<br /> C. TYPE OF OCCUPANCY: 'Commercial `Industrial •Other (specify) 'Variance
<br /> Single family v Duplex No. of Bedrooms No. of Persons__-$'pgC,
<br /> D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms��!,`
<br /> Automatic Washer YES NO Other (specify)
<br /> E. SEPTIC TANK CAPACITY ,./6106 Total gallons No. of tanks _. / __
<br /> 'Holding tank capacity Total gallons No. of tanks.._.
<br /> New Installation ,/ Addition Replacement Prefab Concrete 6�
<br /> ... _........... ..............-
<br /> 'Poured in Place Steel Other (specify) ___._........_
<br /> F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)Z 2) 3' 3) 3_Total Absorb Area ?6?) 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 O° Width /Q” Depth OLIO Tile Depth 3/- 3r'No. of Lines 7...
<br /> Seepage Pit: Inside diameter Liquid Depth Tile Size
<br /> Percent slope of land 2 6,p _.. Distance from critical slope 7.;20'
<br /> I, the undersigned, do hereby certify that the information I have reported is in accord with Section 1-162.20,
<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 cC)f&A y' /9 "44 4"-/,--'/164.2_. C.S.T. # `t r and other information
<br /> obtained from • - a . -,.i (owner/builder). ��j +,�
<br /> Plumber's Signature , � ISIDr� rr MP/MPRSW# Y'G, Phone #p=�-8ia J
<br /> Plumber's Address I/PW' •1 i,L-.t
<br /> PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
<br /> H62.20, including well).
<br /> Roofer vc---7" /IOAv
<br /> 449 re-, by 1-/z a.vT
<br /> Freom -To 1 it T hi e Ls •
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<br /> Do It Write in Space Below - FOR DEPARTMENT USE ONLY
<br /> Date Application `7-.S-7? Fees Paid: StatejO"-- County 0 Date
<br /> Permit sued/Rejected (date) -) S-77 Issuing Agent Name 0_...._.....(/.c_t.`t2_
<br /> tnspecti'Yes No Valid# Date Rec'd__.
<br /> • 1. coumlwhite copy) 3. owner {preen copy) DIVISION OF HEALTH P.O.BOX 309.MADISON.WI
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