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� <br /> Plb 67 �� t'A <br /> State of Wisconsin and County J U L 9 1913 <br /> Uniform Permit Application <br /> for Private Domestic Sewage Systems ' '* <br /> State Permit County Permit <br /> Number Number <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: Name One: <br /> (Sec., Lot, Block) <br /> / ,' CITY VILLAGE <br /> 1S- TOWNSHIP <br /> B. OWNdR OF P OPERTY MAILING ADDRESSS�/)� _ <br /> '? (Street,City, Zip Code) <br /> C. SEPTIC TANK CAPi Gallons NEW INSTALLATION REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete _Poured in Place —Steel--Other ; No.of Tanks <br /> D. TYPE OF OCCUPANCY <br /> One or Two Family Re;.idence -f No.of Bedrooms <br /> Commercial Industrial Other No.of Persons to be Accommodated <br /> (specify) <br /> E. APPLIANCES, ETC.: Food Waste Grinder YES eNO Automatic Clothes Washer _YES NO <br /> Dishwasher YES _ZZNO Other (Specify) <br /> F. EFFLUENT DISPOSAL SYSTEM NEW_. EXTENSION ADDITION —REPLACEMENT <br /> Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines <br /> Seepage Bed: Length Width 7 _ Depth 3 Tile Size f No. Lines <br /> Seepage Pit: Inside diameter Liquid Depth <br /> G. Percent of slope of land % direction <br /> H. Indicate Slope of Land &direction of slope on sketch I. Tile Depth l <br /> PERCOLATION TEST <br /> Indicate Soil map number And Soil Type <br /> Hours Water Test Time Drop in Water Level Inches Minutes <br /> Test Depth Character of Soil Since Hole in Hole Interval Second to Next to Last To Fall <br /> Number Inches Thickness in Inches 1st Wetted Overnight in Minutes Last Period Last Period Period One Inch <br /> It <br /> r r57 <br /> /, 4 <br /> G 'p <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> S O 1 L B O R I GS—Minimum 36" Below Proposed Absorption System <br /> Boring Total Depth Depth to Ground Water Depth to Bedrock <br /> Number Inchhes Observed Estimated Observed I Estimated Character of Soil ith Thicknes in IncKes <br /> c{ Ir <br /> RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> (COMPLETE OTHER SIDE) <br />