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Plb 67 <br /> State,of Vyisconsin and County <br /> Uniform Permit Application <br /> for Private Domestic Sewage Systems <br /> State Permit A/ County Permit 3/ <br /> Number Number <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: +�A(1` i= f•' Name One: <br /> (Sec., Lot, Block) <br /> CITY VILLAGE <br /> (_�c>V L.ry f- I Sc C S 7 1-14, N /5 w CIRC4_ r- TOWNSHIP <br /> B. OWNER OF PROPERTY MAILING ADDRESS 0 <br /> Name (Street,City, Zip Code) M • <br /> H, cb FFo L) UG cL" G51c, IZ M ( fu M , SS 331 <br /> C. SEPTIC TANK CAPACITY �2$U Gallons NEW INSTALLATION REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete Poured in Place Steel Other ; No.of Tanks <br /> D. TYPE OF OCCUPANCY <br /> One or Two Family Residence No.of Bedrooms <br /> Commercial Industrial Other No.of Persons to be Accommodated 3 <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 X EXTENSION ADDITION REPLACEMENT <br /> Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines <br /> n <br /> Seepage Bed: Length �.`� / Width �� r Depth Tile Size No. Lines <br /> Seepage Pit: Inside diameter Liquid Depth <br /> G. Percent of slope of land % 5 w q xxdirection <br /> H. Indicate Slope of Land &direction of slope on sketch I. Tile Depth <br /> ddi <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 /> 304 7 � � IV r✓ 'I 4 � d <br /> 3 3 <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> S 0 1 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 /> t� 4 <br /> 43 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) <br />