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• <br /> .ce DANE COUNTY 1202 Northport Drive <br /> 1.- r:. ENVIRONMENTAL HEALTH DEPARTMENT Madison, Wisconsin 53704 <br /> hC2, +0� Phone 268-4953 <br /> `� PERMIT APPLICATION FOR PRIVATE DOMESTIC SEWAGE SYSTEMS <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED, ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: Name One: <br /> CITY VILLAGE <br /> Nw2t aE SE 4• SEA. lit Till �N kl/4" PhasaNT .cfRIAM-S TOWNSHIP <br /> B. OWNER OF PROPERTY MAILING ADDRESS <br /> Name A (Street, City, Zip Code) PApfsDN/ a)' S. <br /> 4E2C:IIFIIVSIW 0.29/If CM rR1066 AVE <br /> C. SEPTIC TANK CAPACITY I'0 0 0 Gallons NEW INSTALLATION x REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete K. Poured in Place Steel Other ;No. of Tanks ON6 <br /> D. TYPE OF OCCUPANCY <br /> One or Two Family Residence 0 Al E No. of Bedrooms 3 <br /> Commercial Industrial Other No.of Persons to be Accommodated._ <br /> (specify) <br /> E. APPLIANCES, ETC.: Food Waste Grinder X YES NO Automatic Clothes Washer _A_YES NO <br /> Dishwasher X YES NO Other (Specify) <br /> F. EFFLUENT DISPOSAL SYSTEM NEW )C EXTENSION ADDITION REPLACEMENT <br /> Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines <br /> Seepage Bed: Length 3 72 Width Depth 3 ro ~ Tile Size 4 M No. Lines 4 <br /> Seepage Pit: Inside diameter Liquid Depth -. <br /> ,'_ __r c1 <br /> G. Percent of slope of land 1-/0 % g <br /> r �^'! <br /> direction <br /> /S'0/''"`'', = <br /> PERCOLATION TEST <br /> At • 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 /> Example <br /> P- 0 36" NTop Soil 10", Clay 26" 25 yes{or no 30 ' '/z 1 60 <br /> P l 36 " ,/oPSo&& 6 " /1,17L 9:0 y �Z'9 ° So / / / 3o <br /> P..), 3 ` Tosaz6: 1f 29, it'd .'6 a •2 15 <br /> P3 N„ v40/rd ^59110ycANy>'1'' ..,?-4 /14 30 2 2 _ :e ,'s <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> S O I L B O 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 /> Example <br /> B- 0 72", 72" Black Top Soil 12"; Clay 18" Sand 18";Gravel 24" <br /> ,;. ,1 ` , e / % C • • ck. I • . Ct c�MD,t�i e...... -. 24 ' <br /> ti 1 <br /> A <br /> B_3 , my 10 g Ez-,AAl�. ..t- I i `___T'-,1 3o r,,c4110*5 vise 6e -36 <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 />