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PIb,.67 <br />i <br />State Permit T (4 <br />Number <br />y <br />State of Wisconsin and County <br />Uniform Permit Application <br />for Private Domestic Sewage Systems <br />County Permit S <br />Number <br />A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED <br />LEGAL DESCRIPTION: <br />Name One: <br />(Sec., Lot, Block) <br />JJ We" <br />J c <br />A/ N� Sec _T3�/1% D <br />CITY VILLAGE <br />/� I <br />TOWNSHIP <br />B. OWNER OF PROPERTY <br />MAILING ADDRESW J,J C, <br />Name _ <br />(Street, City, Zip Code) <br />C. SEP TANK CAPACITY /670 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. No. of Bedrooms <br />Commercial Industrial Other No. of Persons to be Accommodated <br />(specify) <br />E. APPLIANCES, ETC.: Food Waste Grinder YES Z NO Automatic Clothes Washer YES 1 - NO <br />Dishwasher YES —,Z ---NO Other (Specify) <br />F. EFFLUENT DISPOSAL SYSTEM NEW Z� EXTENSION ADDITION REPLACEMENT <br />Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines <br />i <br />Seepage Bed: Length Width /'o Depth Tile Size No. Lines <br />Seepage Pit: Inside diameter Liquid Depth <br />S <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 <br />Water <br />Test Time <br />Drop in Water Level Inches <br />Minutes <br />Second to <br />Next to <br />Last <br />Test <br />Depth <br />Character of Soil <br />Since Hole <br />in Hole <br />Interval <br />To Fall <br />Number <br />Inches <br />Thickness in Inches <br />1st Wetted <br />Overnight <br />in Minutes <br />Last Period <br />Last Period <br />Period <br />One Inch <br />- G J%j, <br />7o <br />C5 <br />12 <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 <br />B 0 R I N G S— Minimum 36" Below Proposed Absorption System <br />Boring <br />Total Depth <br />Depth to Ground Water Depth to Bedrock <br />Observed <br />Estimated Observed <br />Estimated <br />Number <br />Inches <br />Character of Soil with Thickness in Inches <br />3S <br />i <br />t t <br />3 <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 />