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Plb 67 . -� ' <br /> rt-. ,k' 11 ,4 State of Wisconsin and County <br /> iUniform Permit Application <br /> ,,.;y—x .,, Date <br /> for Private Domestic Sewage Systems <br /> County <br /> State Permit <br /> Number Permit Number <br /> A. OWNER OF PROPERTY <br /> Name: Mailing Address: <br /> cX// ✓ t s4(4i 4'J 1. %e 14-7,G ©,0 4 /iv. S'/Pi -fY2/ <br /> B. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: Name One: <br /> (Sec., Lot, Block,etc.) CITY VILLAGE <br /> ,544,/5>' TOWNSHIP <br /> C. SEPTIC TANK CAPACITY 750 Gallons NEW INSTALLATION X REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place Steel )1• Other ;No. of Tanks ( <br /> D.TYPE OF OCCUPANCY y OAC. <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 )' NO Automatic Clothes Washer YES NO <br /> Dishwasher YES )( NO Other (Specify) <br /> F. EFFLUENT DISPOSAL SYSTEM NEW e$ EXTENSION ADDITION REPLACEMENT <br /> Seepage Trenches: No. Lin. Feet "J"f4"`" Trench Width .•141r ' Depth Number of Lines" <br /> 16/46 <br /> f� if <br /> Seepage Bed: Length /`p ,.Width Depth -it. Tile Size 7 No. Lines <br /> Seepage Pit: Inside diameter Liquid Depth <br /> G. Percent of slope of land +Q % direction <br /> H. Indicate Slope of Land &direction of slope on sketch I. Tile Depth 4R <br /> /If <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 eriod Last Period Period One Inch <br /> / . 10,, 4 7S.1cr y ikr,: `1' . /8 &► _ i'2.. <br /> A <br /> 3 .3c,. ,�/S•�v /i <br /> %7y' ' /,-U m', 3 ' - j74t 9 _'a14 <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 yCharacter of Soil with Thickness in Inches <br /> / 46 �1� f GIl��C .t fi--' /7Ch �r t + >�i #9'I SfQpri4 <br /> 2. 44 N ,/ ` ufiAkt,t,,,.- G.'t , t' ' C ) 4vc it <br /> RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> I!`/IrADI ETC /ITL1 CD C IIICI <br />