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ers sz d.^-rr. _sons, ,s <br /> ` State of Wisconsin and County <br /> C Uniform Permit Application Q <br /> for Private Domestic Sewage Systems <br /> State Permit County Permit S <br /> Number Number <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: //., ,r, '--'�i� •t �f1Name One: ' <br /> (Sec., Lot, Block) CITY VILLAGE <br /> NSHIP <br /> B. OWNER OF P-ROPERTIV�Dii� i-" �„.r�(,a /J, MAILING ADDR SS <br /> (Street,City, Zip Code) - <br /> C. SEPTIC TANK CAPACITY _PS 'U_/GaIkms NEW INSTALLATION /' REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concretey Poured in Place Steel Other ;No.of Tanks / <br /> D. TYPE OF OCCUPANCY ('') <br /> One or Two Family Residence / No.of Bedrooms <br /> Commercial Industrial Other No.of Persons to be Accommodated <br /> (specify) <br /> E. APPLIANCES, ETC.: Food Waste Grinder _VES ANO Automatic Clothes Washer _YES LINO <br /> Dishwasher _VES /NO 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 __/_ __ Depth Tile Size 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 L Tile Depth �- <br /> PE RCO LATION TEST <br /> Indicate Soil map number And Soil Type <br /> Hours Watcr Test Time Drop in Water Level Inches Minutes <br /> Test Depth Character of Soil Since Hole [in Hale Interval Secod.t Next toLast To Fall <br /> Number Inches Thickness in Inches 1st Wetted vernight in Minutes Last Period Las[ Period Period One Inch <br /> 1 <br /> RECORD DATA FROM MINIMUM OF 3TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> S O 1 L B O R I N G S- Minimum 36" Below Proposed Absorption System <br /> Boring Total Depth Depth to Ground Water Depth to Bedrock , <br /> Number Inches Observed Estimated jObdEstimated Character of Soil with Thickness in Inches <br /> 1/ <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 />