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State of Wisconsin and County <br /> Uniform Permit Application <br /> for Private Domestic Sewage Systems <br /> State Permit County Permit �� <br /> Number Number <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: Name One: <br /> (Sec., Lot, Block) 8` <br /> CITY VILLAGE <br /> ^ ,r g�.��''r TOWNSHIP <br /> B. WNE OF PR ERTY MAILING ADD SS <br /> Name (Street,City, Zi o e) <br /> C. SEPTIC TANK CAPACITY ._ .2.1V 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 c_ � N NO Automatic Clothes Washer YES O <br /> Dishwasher YES A1<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 /> H. Indicate Slope of Land Idirection of slope on sketch I. Tile Depth <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 /> / 31 ,r If /t 4 <br /> 36 <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 /> RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> (COMPLETE OTHER SIDE) <br />