Laserfiche WebLink
J <br /> DANE COUNTY 1202 Northport Drive <br /> jr ' Madison, Wisconsin 53704 <br /> h;,hr'.n ENVIRONMENTAL HEALTH DEPARTMENT <br /> t2�j�� Phone 266-4953 <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 /> 5 Y 4 f set./ sec. 35" T 7/r R / 0 !—e/-e—TOWNSHIP <br /> B. OWNER OF PROPERTY MAILING ADDRESS <br /> Name (Street, City, Zip Code) <br /> re- 4dlAid le, pti at./ <br /> C. SEPTIC TANK CAPACIT/4 ,QGallons NEW INSTALLATION c 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 X Industrial Other No. of Persons to be Accommodated <br /> (specify) <br /> E. APPLIANCES, ETC.: Food Waste Grinder YES X NO Automatic Clothes Washer ___YES NO <br /> Dishwasher YES k 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. CO) Width ":7° Depth 3 6 Tile Size 9" No. Lines 4/ <br /> Seepage Pit: Inside diameter Liquid Depth <br /> G. Percent of slope of land 7 % .5 E direction 0") <br /> PERCOLATION TEST <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 /> Example <br /> P- 0 36" Top Soil 10", Clay 26" 25 yes or no 30 1 1 '2 60 <br /> P 1 3 ' v ? Soi L/o"0/14'SV 07,• lie JO R._ sr s2-0 <br /> Y <br /> PZ 36" T�So;Lio" c'.Qo.pc� ��-. rlld Sa �� 37�/ ' �a <br /> P3 31 " 7"0 ,$,,�L /c" Ch,-.2.41". 3-3- _ NO -3° yr 1r V' .,� <br /> RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED <br /> S 0 I L B O R I N G S—Minimum 36" Below Proposed Absorption System <br /> Boring Total Depth Depth to Ground Water Depth to Bedrock <br /> Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches <br /> Example <br /> B- 0 72" 72" Black Top Soil 12"; Clay 18" Sand 18";.Gravel 24" <br /> 11. 7..2. 't jo / i / a/.. Ira,"... ;L /c ',,, , " s 38'' <br /> 7' " 0 / G ( ae*hr$,'L /"" W& al" l 3i <br /> 6-3 7). �fD 1 .: - ,.So:L/ 0"Ctlit, 3o ., g �, 32" <br /> RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYST / IS TO BE INSTALLED <br /> (COMPLETE OTHER SIDE) <br />