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1 — — _ , 4 <br /> P1b67, ***520.44.. • <br /> 1 V;Q l, • <br /> ' ` r .L 1 I State of Wisconsin and County <br /> +-+ � / Uniform Permit Application <br /> ' ' for Private Domestic Sewage Systems Date <br /> • <br /> State Permit County ' <br /> Number Permit Number <br /> A.OWNER OF PROPERTY f <br /> Name: Mailing Address: <br /> B.LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTERED OR EXTENDED <br /> LEGAL DESCRIPTION . f r, f +±, Name One: <br /> (Sec., Lot, Block,etc.) 'i ".' `;, 'AV; t 1 �' CITY VILLAGE <br /> arJ Vi If... ... t.-_ •1..;..0. ' ; . I'-' ., ,�{ TOWNSHIP <br /> C.SEPTIC • 'K'C•''•' �'° . , a ons NE NSTALJ•TION _� REPLACEMENT ADDITION <br /> 3 <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 l ; <br /> (specify) <br /> E.APPLIANCES, ETC.: Food Waste Grinder —60 YES NO Automatic Clothes Washer—YES NO <br /> Dishwasher ytr YES NO Other (Specify) <br /> F. EFFLUENT DISPOSAL SYSTEM NEW a EXTENSION ADDITION REPLACEMENT <br /> Seepage Trenches: No. Lin. Fe9t Tr nch Width Depth Number of Lines <br /> Seepage Bed: Length 1 Width Depth 3 Tile Size 'V~ No. Lines <br /> Seepage Pit: Inside diameter Liquid Depth <br /> G.Percent of slope of land / % S direction <br /> H. Indicate Slope of Land&direction of slope on sketch I.Tile Depth R <br /> /Ito <br /> PERCOLATION TEST <br /> Indicate Soil map number <ICC—/G S And Soil Type Goo'" 1 <br /> Ts-4 r Hours Water Test Time Drop in Water Level Inches I 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 /> 4 Ar' 2/ 25 no 36 .20 0 Zy/ /3 <br /> ft /I` If S Of n, of 2 //e /% X <br /> 2.• IS /P IC <br /> �" RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED/ <br /> • SOIL BORINGS—Minimum 36" Below Proposed Absorption System / .114 Dy aim, <br /> Boring Total Depth Depth to Gr.c{nd Water -Depth to ggdrock �/r1i A4 - ' f . <br /> Number Inches Observed stimated Observed Estimated Character of Soil with Thickness in Inches <br /> 1 17 Fa rma, ls'" d N x 7 I <br /> "' /6- 4 3/ � as" <br /> • <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 />