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� S , <br /> Plb 97 <br /> State of Wisconsin and County <br /> Uniform Permit Application Date <br /> for Private Domestic Sewage Systems <br /> County_ <br /> State Permit ti <br /> Number Permit Number <br /> A. OWNER OF PROPERTY <br /> Name: Mailing Address: <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 /> TOWNSHIP <br /> C. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION _ REPLACEMENT ADDITION— <br /> MATERIALS: Prefab ConcreteI Poured in Place Steel Other ;No.of Tanks <br /> D.TYPE OF OCCUPANCY 1� <br /> One or Two Family Residence r` r ) ., �� �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 EXTENSION ADDITION REPLACEMENT <br /> Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines — <br /> Seepage Bed: Length Width DepthTileSizes 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 _ <br /> PERCOLATION TEST <br /> Indicate Soil map number And Soil Type <br /> Hours Water Test Time­- Dropin 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 /> 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 Proposod Absor ion Svstem <br /> Boring Total Depth <br /> Number Inches Observed stimate erved stimate Character of Soil with Thickness in Inches <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 />