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el b 67 <br /> State of Wisconsin and County <br /> *P! <br /> Uniform Permit Applicationfor Private Domestic Sewage Systems 7 `� _ County Permit J 7 7 J <br /> Number J Number <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: Name One: <br /> (Sec., Lot, Block) s .-�'+^o` <br /> • I CITY VILLAGE <br /> OAk6-A.N_U—TOWNSHIP <br /> B. OWNER OF PROPERTY MAILING ADDRESS <br /> Name (Street,City,Zip Code) <br /> ,NGS4��—�ES7 UAKI;VI ,Lr N1NN. 5-,)-z,Lf <br /> C. SEPTIC TANK CAPACITY 7_K.7_Gallons NEW INSTALLATION K REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place —Steel_X Other —;No.of Tanks <br /> D. TYPE OF OCCUPANCY , ' <br /> One or Two Family Residence — I No.of Bedrooms <br /> i <br /> Commercial Industrial Other No.of Persons to be Accommodated 4 <br /> (specify) <br /> E. APPLIANCES, ETC.: Food Waste Grinder _YES x_NO Automatic Clothes Washer X__VES — NO <br /> Dishwasher _VES X,—NO Other (Specify) <br /> F. EFFLUENT DISPOSAL SYSTEM NEW-I( EXTENSION — ADDITION _REPLACEMENT <br /> t <br /> Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines <br /> Seepage Bed: Length .a �r Width _(_'a Depth A2. Tile Size, y" No. Lines <br /> Seepage Pit: Inside diameter Liquid Depth <br /> G. Percent of slope of land —0 % direction <br /> H. Indicate Slope of Land &direction of slope on sketch I. Tile Depth_ L <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 Nezt m Last To Fall <br /> Number Inches ,.Thickness in Inches 1st Wetted Overnight in Minutes Last Period Last Period Period One Inch <br /> op5elt IAC � <br /> / fes_►;�-�.u�1a -y LS —�� 3 y � N>=Ly� "I <br /> r <br /> r <br /> RECORD DATA FROM MINIMUM OF 3 TEST 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 /> Bering Total Depth Depth to Ground Water Depth to Bedrock t <br /> Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches <br /> I I op sofa, sa.,::„ c ev sQ Ik I <br /> RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> (COMPLETE OTHER SIDE) I <br />