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Plb 67 ' <br />State Permit <br />Number <br />State of Wisconsin and County <br />Uniform Permit Application <br />for Private Domestic Sewage Systems <br />County Permit <br />A. LOCATION OF PREMISE WHERE SYSTEMWILL B C N TERED OR EXTENDED <br />LEGAL DESCRIPTION:iej CL (2U���j ��„ ��r,G t3v,Z^��_�-T Co <br />Name One: <br />(Sec., Lot, Block) <br />�V 1,rs 3 S'h_ a 3 rq<j /4 11 Itr kA/ <br />_1�5awITY VILLAGE <br />/y <br />TOWNSHIP <br />B. OWNER OF PROPERTY <br />MAILING ADDR:EJSS <br />Name <br />(Street, City, Zip Code) <br />i)cv l? 1= S P/=/-►1� 5 <br />5 r, J'A v 0 ivy / /V <br />C. SEPTIC TANK CAPACITY 12 GG 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 � <br />(specify) <br />E. APPLIANCES, ETC.: Food Waste Grinder YES X NO Automatic Clothes Washer X YES NO <br />Dishwasher YES 1� 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 Tile Size No. Lines <br />Seepage Pit: Inside diameter Liquid Depth <br />G. Percent of slope of land % direction <br />�a '1 <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 />:TD4gppssAIAcjys <br />1st Wetted <br />Overnight <br />in Minutes <br />Last Period <br />Last Period <br />Period <br />One Inch <br />l <br />�`'� <br />3 a � <br />Ivy <br />s <br />� � <br />�r <br />`� <br />► a .� <br />`t <br />3 1 l <br />lac. <br />5 <br />N <br />q S <br />l ..I I <br />3 <br />3 <br />3 � <br />x,17 <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 O R I N G S— Minimum 36" Below Proposed Absorption System <br />Boring <br />Total Depth <br />Depth to Ground Water <br />Depth to Bedrock <br />Observed <br />Estimated <br />Observed <br />Estimated <br />Number <br />Inches <br />ter of Soil ckness in Inches <br />% 1 <br />k <br />w n► <br />3 y <br />7 <br />(e <br />3 <br />L eTA r! A nninnnnl lM r);: 3 RORE HOLES <br />IN THE <br />AREA IN <br />WHICH THE SYSTEM IS TO BE INSTALLED <br />