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HomeMy WebLinkAbout018-1055-10-000 / 2 § § f C. / § « k� UCL / 77 / @ OS § § =f - 8 c �7 , cc c@ � =:o8 [AM�p 0 ®k7 ) k \ )\ kƒ§ LL / %fD \ t� 2E < . 5£ ;= c , o � « § � / § E z / k k ,It m k a m e m . � ( B k r t — J } � 2 _ ® k 2 CD , 7 D / § � Q } ) z .. C14 § / \ 4 E e 6 a. ° k = k - E / § k a. \ f k $ k _ , .. \ \ \ \ 7 a a a CO q 7ƒ �) § 2 / / § 6 2 \ } § k = /E / k 2 ( W k <co 2 3 \ ) } /§J -2 § B § § / . / / 2 2 @ 2 / / 11 \ E $ =ch 7 7 f f / / / % 2 LL o 13 ) f I \ 2 2 M { C E c k J a 3 0 P3b67 7/71 Wisconsin Department of Health and Social Services Division of Health SEPTIC 'TANK PERMIT APPLICATION . MAY 1 5 lyil TYPE OR USE BLACK INK - PLEASE PRINT PLUMBING A. - OWNER OF PROPERTY Nase Address (Street, Citys Z�ip/ Code) B. LOCATION OF PROPERTY WHERE SYS7124 WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY`✓ , r U o lx Check Ones Aj PP At 3°tO CITY�� ' VI E LEGAL DESCRIPTION TOWNSHIP (Block,;Lot, Sso.) +. - • y Sat, Syr rV70W e 7k) LOCAL PERMIT REWIRED FOR THIS WORK? YES _`.No PERMIT NUMBtR D. SEPTIC,TANK PAPACITY f GALLONS NEW INSTALLATION REPLACEMENT ADDITION _..� _.� MATERIALSr;',PREFAB CONC1tETE Y .12 46 PLACE��STEEL OTHER NMER OF.TANKS'TO BE INSTALLEDs E. TYPE OF OCCUPANCY Check Oases One or Two Family_Residence Commercial-,Industrial Other (Spsoify) Number'of,persons to be Accommodated Number of BedroomsT Fe 'APPLICANCES, ETCs " Food -Waste Grinder YES JNO NO Automatic Clothed Washer YES., NO Dishmasher YES NO Automatic Potato Peeler YES NO OTHER (specify) YES G. MASTER PLIMBE,RfMAKING INSTALLATION Names, Address: SIGNATURE OF APPLICANT sr0441�l,r y,, License Nunbers MP�7 ADDRESS, ". . .' "V+'t 1 J MP RSW. H. (TO BE COMPLETED BY ISSUING AGENT) Date of Application Foe Paid Persist Issued (date) Pend* Number Age (ndllss) Fors toxnt village, city, oownkyj sto. ((specify) NOTE, The Application cannot be considered for filing until all of the above questions,are answered and the fee paid. Agents will forward application, the fee of ;1.00 for each septic teak and, the third copy of-.the permit (canary) to the.Division of:Health. .Cheeks and. coney orda4.shauld, be made payable to the Division of Health. COMPLZTE OTHER SIDE Y. r.. ., NAME: r 0 p 7 S! COMM S f• /t° l�` SEPTIC TANK PERMIT NUMM j REPORT ON SOIL PERCOLATION TEST AND SOIL BORINGS TO DIVISION OF HEALTH —PLUMBING SECTION P.O.BOX 309, Madison, Wis. 53701 Pursuant to H 62.20, Win. Administravive Code P E R C O L A T I O N T E S T TEST DEPTH CHARACM OF SOIL HOURS WATER TEST TIME DROP IN WAT R 'VEL INC MINUTES NUMBER INCHES THICKNESS IN INCHES SINCE HOLE IN HOLE INTERVAL SECOND TO TEXT TO LAST TO FALL EXAMPLE let WETTED' OVERNIGHT IN MINUTES LAST PERIOD LAST-PERIOD PERIOD ONE INCH . P — 0 36" TOP SOIL 10x CLAY 261r 25 YES OR NO 30 60 3 77 RECORD DATA FROM MI N Z OF 3 ?EST HOLES COMPUTE SIZE OF ABSORPTION AREA IN ACCORD WITH H 62.20 WIS., ADMINISTRATION CODE. S O I L .B 0 R I N G S — MINIMUM 36" BELOW PROPOSED ABSORPTION SYSTEM BORING TOTAL DEPTH DEPTH TO GROUND WATER DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED OBSERVED ESTIMATED CHARACTER OF SOIL WITH THICKNESS IN INCHES EXAMPLE B - 0 r 7211 BLACK TOE SOIL x O x. SAM 18n. gauL to s 2 60 `� ?. {J 3 / w / RECORD DATA FROM INIIH7M OF 3 RARE HA TIM TYPE OF OCCUPANCY: RESIDENCEt NUMBER OF BEDROOMS OTHERS (SPECIFY) �`�r`��d A NUMBER OF PERSONS FOOD HASTE GRINDERS YES_ NO ) DISHWASHER: YES N0_,� AUTOMATIC CLOTHES WASHER: YES��NO EFFLUENT DISPOSAL SYSTEMS NEW `( EXTENSION ADDITION.' REPLACEMENT TILE SIZE NO. LIN. FEET WIDTH DEPTH NUMBER OF LINES_+� I I ' SEEPAGE BED: LEN � " GTH4j NID ii DEP?Ii: Y TILE SIZE NO. LINES SEEPAGE PITS INSIDE DIAMETER LIQUID DEPTH I, the uAdersigned, hereby certify that the percolation tests reported on this form were made by me or under qj super- vision in accord with the procedures and method specified in Chapter H 62.20 (3 ), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of /myy knowledge and belief. NAME IC �L+� L.M4,,C� Ak)J</IV S TITLE TYPE or PRINT REGISTRATION NO. OR MASTER PLUMBER LICENSE N&, � ADDRESS I n] DATE /A "`_7/)�f� SIGNA /'KL�t.�i.•�.,s DO NOT WRITE IN SPACE BELOW - FOR DE PAIMIENT USE ON 4X DATE RECEIVED ACCEPTED BY RETURNED FEE RECEIVED VALID NO, PERMIT NO. 1-REVIEWED BY APPROVED DATE r 1 if Y^ i�1Yl�'Milllr � ,j, � �� .�"�.. r n. y�j Yom,,�• .n�,,s a s Ar it r qp�. . i till ` y yi T N © � 60 f .i�'.-A",..�� ,w }� 'W �.,,f`r��`�� 'C� v 7•� � � :.� � �� �- +��+: +lyNgt yllM`ry , - � r�S�_ 4� �'. wq...Niry..l,t. ^�++.ay.:...r• , �y�,,, ,.".. t i+"�"r+�,"'y +�W+�►y+�ww � '� x .� rcl"'e � r ��`,. +� t ` ` f pt ,V��•�+,' ': x� .: Pd`''c r : `�k�i ''�c'{ih'�`i>•k, �, �rf�n 3 7- ,.k i y rCk TM� � '�}�, q'y",+ti;r '..� 3": a k� •s'�` s� 't���'�I3"�x- � 4 '�:rx�� T x� S tom`-�``a�'°� �6 �.r #� 4+� �' .mss' -s Y m,�- t v1, z✓ '� �.Y :ter m "� f ,. .. ^. 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