Laserfiche WebLink
N • <br /> Plb67 ,' <br /> 11 r ; 1 State of Wisconsin and County <br /> Itw 1 Uniform Permit Application <br /> -- for Private Domestic Sewage Systems Date <br /> County <br /> State Permit <br /> Number Permit Number <br /> A. OWNER OF PROPERTY <br /> Name: Mailing Address: <br /> 2,i.a /I , . <br /> t ,s <br /> . LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: Name One: <br /> (Sec., Lot, Block,etc.) CI VILLAGE <br /> TOWNSHIP <br /> fri// Ski ,S3S 747f6P//? if 14V <br /> C. SEPTIC'TANK CAPACITY 1J'S(,JGallons NEW INSTALLATION REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place Steel Other ;No. of Tanks <br /> D.TYPE OF OCCUPANCYa. <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 YES YNO Automatic Clothes Washer YES NO <br /> Dishwasher YES b0 Other (Specify) <br /> F. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT <br /> Seepage Trenches: No. Lin. <br /> Feet, Trep9 Width Depth 14 <br /> Number of Lines <br /> 9 Ta <br /> Seepage Bed: Length Width Depth 3' Tile Size 7u No. Lines a <br /> Seepage Pit: Inside diameter Liquid Depth s <br /> G. Percent of slope of land -Z % * direction <br /> H. Indicate Slope of Land &direction of slope on sketch I. Tile Depth -Z-. <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 /> 3` f , r /D" •. .2t to. / 4 4 5- ,,G G , SRO <br /> // �j/ 4 ' L '. I f <br /> �`//tr f f `� I /r �41 "t/ `1D f f S-G (. <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> SOIL BORINGS— Minimum 36" Below Proposed Absorption System <br /> Boring Total Depth Depth to Ground Water Depth to Bedrock <br /> Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches <br /> l ) <br /> 2 r' 7 a? ,e /yap 7" .S /! "-- =.tr/ C,2 ' <br /> RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> IIYIrADI CTC 11T1JCD C1IlC1 <br />