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P I b 67 <br /> ';IV State of Wisconsin and County <br /> Ii [ Uniform Permit Application <br /> ,'!;.t 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 /> _ SEC <br /> �/� / �f CITY VILLAGE <br /> AI <br /> UL) Ni �CC .3-737 /AR )(k!/l� /465-a,E'47- TOWNSHIP <br /> B. OWNER OF PROPERTY MAILING ADDRESS /\9 ( <br /> Name 1 (Street,City,Zip Code) ,\ <br /> C. SEPTIC TANK CAPACITY / Gallons NEW INSTALLATION yREPLACEMENT X ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place Steel /1 Other ; No.of Tanks / <br /> D. TYPE OF OCCUPANCY 4/ 3 <br /> One or Two Family Residence A No.of Bedrooms ` <br /> Commercial Industrial Other _ No.of Persons to be Accommodated <br /> (specify) <br /> E. APPLIANCES, ETC.: Food Waste Grinder YES X NO Automatic Clothes Washer YES NO <br /> Dishwasher YES 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 cG Tile Size Y No. Lines <br /> .j4.5 <br /> Seepage Pit: Inside diamet r a Liquid Depth <br /> G. Percent of slope of land 6% direction <br /> H. Indicate Slope of Land &direction of slope on sketch I. Tile Depth <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 /> / ..��.. , _ <br /> WI, , Je,t () .S/Q/�D � 7zC) /0 e2— �-" �-• ( _. <br /> Z SO X r ; ' G / a �-` 1 <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> S 0 I L B 0 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 Observed Estimated Character of Soil with Thickness/in Inches / <br /> / Fr 'y --->„, A-4 ,..1,/,(' A, C,_:!,t.. 1C) 30:Z. l 'rl <br /> / '' i <br /> ,,,fi A <br /> S7 - is <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 />