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P1b67 <br /> ' •%37 ' State of Wisconsin and County <br /> �'':_40 j i Uniform Permit Application <br /> for Private Domestic Sewage Systems <br /> State Permit `County Permitt <br /> Number Number, <br /> A. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION: 4071-ge'�A S`,5 7T/ 4 n •Name One: <br /> (Sec.,Lot,Block) y 9 <br /> CITY VILLAGE <br /> anrri' • 6# ekETOWNSHIP <br /> B. OWNER OF PROPERTY MAILING ADDRESS )f r. ce)ns be ARS> <br /> Name . /4114 /1Clt91!4, (Street,City,Zip Code) sre et 9/1 7d 41 11)"5( , <br /> Gf.1i l,i4 t 8c1/%4'E>Ps <br /> C. SEPTIC TANK CAPACITY 0 Gallons NEW INSTALLATION t ' REPLACEMENT ADDITION <br /> MATERIALS: Prefab Concrete t----- Poured in Place Steel Other ;No.of Tanks <br /> D. P OF OCCUPANCY <br /> e Two Family Residence 01tL No.of�m . -3 +!• <br /> Co ercial Industr' D, e . ,• f4.. ..of Persons to be Accommodated <br /> specify) "( <br /> E. APPLIANCES,ETC.: Food West Grinder DES- ==s-"�'' Automatic clothes Washek YES — NO <br /> } <br /> ����� Dishwasher r YES __NO Other(Specify) pp <br /> F. EFFLUrENT DISPOS SYSTEM NEW EXTENSION ADDITION TJ�EPLACEMENT <br /> ■ <br /> Seepage Trenches: No Lin.Feet , , Trench Width ; •i, Depth Number of Lines <br /> Seepage Bed: Length `1 _, Width a- Depth ` Tile Size !ff i No.Lines a <br /> Seepage Pit: Inside diameter I . kL(quid Depth 'r' y <br /> O�Ji f fi <br /> G. Percent o�sigpsOf lab 3 - i direction i <br /> H. Indicate Slope of Land&direction of slope on sketch I: Tile Depth W -/"Sv <br /> 0 PERCOLATION TEST <br /> Indicate Soil map number 3 LA., `' a And Soil Type 3 S s" <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 Fall <br /> V. t «.-". _� - _". +f�t�. . _ ������__a�� a eriod Period One Inch <br /> umbe ncbet ThIc4ness in Inches _ tted_ Qvernight jn Minutes Last Period Last <br /> -Ti. <br /> /y <br /> 1. 3e f'r S ,1;a7pksl ` I 3 r 1 '''.2, 1 a 0 <br /> III 3 .3e. rTe ld'Ati:ity <br /> RECORp D TA F OM MINIMUM OF 3TEST HOLES IN THE AREA IN WHICH THE S'(STEM IS TO BE INSTALLED <br /> S O I G a) .b 6 I .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 /> 7/1 — /0' - j0' 7 "rep S../) n'CfAy j 3�',Sawdy eky <br /> �a -7G (6" 3O' 9"Top Soil ;.ir'C�M/) .3r5off./ ! / <br /> 3 79'' G C' -- 3 0' . it �3 7''+. J .�y `.a•�,/ <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 />