HomeMy WebLinkAbout036-1008-40-000
z ^P n to O 3
"a a d
o ~ ~ III r
i
I d
A -
3 - 0
Cn -1 2 - Z OD N (n (n O O '1
N •
I, n D~ O N N O W o w m? W
n. Z Q. y A CD j O 1
A 7 ~ CO N v O 00
= O to p
N a
CD -0 0 :3 (D
C) I CD CP
3 O N o O
N_ N a O O O !r•
U] G' C!] ~ ~ ~ in A O
~ N• rt N• I m u> ~ D A a
O W 7J n CD N W C
rt W 3 CL rn rn cn
rt b - O
ri F "t O A <
N N O c
00 CO ~n
i ri• W O N
^ a
(D ~ 3 a
z o o o firs
(D Z O O O
N• w ° C D CD < Z
rt H v =3 C
3 vi co cn o D
00
N O cr v G v O (D CA
N O= j M y 't' III A
U-1 CD N !'r
ON 4-
N O d o
W N Z D
ON a cn
N
0~ Z
° Z D W 03 z
O 0
CL ~r
(D
rn n 0' m m N
m t~l
CD v
41
C
c CAD CD
I a ~ W a
a° ` rt a 3
N Z CD y
r N ni
rt X
O w a A
ca -0 < W A
I
Z
V 00 :•r Z
M
D A
W ~
CD
CD
CL a 3
d
o -
0
3 v
I 'o a o. I
CD
N m
o.
y
CD
y
a A
c I `
m
a
CL N
w
N ' N
~ O
- O
CL v
I ~ A
CD .
p b b
o arw _ 11
.Umro,~ugn.rj°'iv
~ f
00'0 00'0 00'0 lelol
soBJeya;uenbullaa soBJeya leloadg s;uawssessV leloadg
;unowV fjoBa;ea apoo leloadg Jasn
:sleloadS
W # 4ole8 :a;ea uol;eourpoo 6 :;unoo wlelo :jjpaJC) AjollO-i
0 0 000'0 puelpooM
001,'991 001'9£1 000'0Z E9E'Z AljadoJd IeJaua0
:9002 Jo; sle;ol
0 0 000'0 PUelpooM
001'951 001`9£1 000'0Z E9£'Z A)jedoJd IeJau80
:9002 Jo; sle;ol
ON 001'991 001'9£1 000`0Z £9E'Z 1J -IVI1N341S3b
uoseaa a;e;g le;ol anoidwl pue-1 saaov sselo uol;dl.iosea
1700Z/170/90 :PaBueya ;set :suollenIBA
009'9e 1 179£991
:y;lnn possessV :anleA;aIJeW J!e-A # Ma kuvwwns 9002
£59/L179 L661/£Z/LO
1761/11L L661/EZ/LO
LL 1/175L L661/EZ/LO
OD 1117/5951 00617£9 OOOZ/LO/Z 1
adAl aBed/IoA # oo(3 a;ea
:tio;slH IaoJed :sa;oN
3N MS ML 1-N 1£-170
(17/1091 17/1017 Buhl-UMl-oaS) :(s);oeJl
(Ot/ E9£'Z) 1
1010-I :BPIB opuoa/)Ioole 101 9501-17 WSO 3N MS id ML 12i N 1El 17 03S
-9E0 9901/170 WSO-9901 :teld £9£'Z :saJOV :uol;dlJosea IeBe-1
O11M OOL1 dS
4NOWHOIb M3N Z96£ OS
Ant/ H15£Z 17591 x uol;dlJosea #;sla ads jL
tiewud :(sa)sseippV ApadoJd leloadS = dS I0043S = OS :s;olj;sla
9Z0179 IM 31 JIVJd 2:WiS
3AV H15EZ 17991
N NtflbB 'Wf1XAH - O WnX3H N NVRJB
jaumo-oo 3uaaino = o 'jaumo luaiino = o :(s)Jaumo :ssaJppV xel
0 00
adAl;lwaad #;!wJad # uol;eollddb eeiV seleg # deyN a;ea IeolJO;sIH a;ea uol;eaJa
NISNOOSIM '.11Nnoo xioHo '1S X ;u9JJn3
NOlNt/1S AO NMOl - 9£0 819'L 1' 1E'17 IaoJed 'IIV
L 30 4 3`JVd
AV 9Z:60 LOOM MO 000-OV-800 4-9£0 Iaoaed
0 cn 0 0 cn 0
o v f d f c m O
c c = o 3 c►►
(D 7 N (D (D 'B a: •
C m 1
3 m
3 - - _
'D 3 p Q Q O Pe Cn d _ O_
a CD CD CL (D 0 C:)
(n ~I W C L
= N CA = F (D CO
N ~ O 77 N U
O L 0 37.) 01)
O 'r = m c O _ !C CA CD
6'.
CY) o v Q c N o o *~w
L._.
N N N W
C p~
LT,
G ID ° z ,D Q a
(D (D (n CL O (s Q N
y
~ O W C U1
C O O - O O cn 01 ::r
7m) >
■ A A D O O CD
z co co o (n (7 r N
0 co 00 cn Cn o c
N N o o m g ra
O O O OC OC OC
o m < G G
(D i
'U O D n o
v O O
O N (Ii (D N A A
_ d 'O p ~ N •O ON ~ \y
(9 ((D N p~ (D = m cL] N
w N m < N N
3 o
N - -
m CD
z
O zD m z z C/) z
c- =3 ID
0 _0
-b 0)
75 25 CD (D C (D N •
<D w S ^ - a rye
m 1 m m 3. V Q
L Q N. to
L"' N (D = Cn
n
v
E
z e E -i Cn
`p Z (D
U o it o , ;fin,
a A O 0
O
= Cn -I A
(D m CD m
- ,
a z
a
0 3 0 3 i'
" O
O z
3 m
z
(D (D
A
W ~ N
O
(D _
= O 3 N -
(D N U p
(D (D
CD-
-n N T
Ott: C ~ i~-C
N G O v iv O.
(D CID
(D O CD
v
= N V v0 3
~
a a N 0
1
cn
7 M
O
q
O 3
Q
O ET O `
C =
O "
Q cn
(D
_ (D N
c
(D ~ v
C O N
(D p O
(n
0 N
O_ O ~ O
(D (,D 7G O
0 Efl 0 cT
O D O C
O ( CD 0 O
Wisconsin Department of Health and Social Services
Plb. l'67 1069 Division of Health
PE LIMIT APPLICATION
for
PRI'Jr.TE DCaESTIC SEWAGE SYST::"!S
A. OWNER OF PRCPc:FrPY TYPE OR US BACK I?+K
Name Address (Street, City, Zip Code)
.
f i County
B. LOCATION OF PROPERTY WH..i:E SYSTEM WILL BE CONSTP-liCTFI), ALTE2:D jR FXTE-NDED
Check One: C
CITY VILLAGE LEGAL DE>rP.IPiIONT: 1 J {y IV TOWj,SPIr
C. IS LOCAL PERMIT REOUIPED FOR THIS WO YES NO PEW. .IT NLTI?ER
D. SEPTIC TANK CAPACITY Gallon3 NE74 INSTALLATION REPLACF_[KNT ADDITICit
MATERIALS: Prefab Concrete ti Poured in Place Steel Other
NMJER OF TANKS TO BE IVSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Co mercial Industrial Ot:^.>_r
(Specify)
Number of Persons to be Accommodated 1 Number of Bedrooms
F. APPLIXNCES, ETC: Food Waste Grinder Y'S V NO Automatic Cloches Washer YES NO
Dishwasher YES NO Autoraatio Potato Peeler YES NO
Other (Specify)
G. EFFLUF.NP DISPOSAL SYSTEM NEW EXTENSION ADDITION REPt CE NT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length Width _ Depth Tile Size No. Lines
Seepage Pitt Ix+de diameter Liquid Depth
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Droo in Water Level Inches r!inutas
Number Inches Thickness in Inches Since Hole in Hole `Interval Second to Next to Last To Fall
1st Wetted Ovarni ht in Min- .es Trst Per'_od L=as: Period Period One Inch
Example _
P- 0 36" To Soil 10C2625 es or no 30 112 1/2 1/2 60
R•_'.CJ=D r-i7A F, I ^ CF 3 7v-S? HOLES
ompute size of absorption art i in acoord with H 62.20 Wis. A.dninistn :ive Code.
S O I L B 0 R I N G S - Minimum 36" Pelow Proposed Absorption Sys'en
Boring Total Depth Depth to Ground Water Depth to Bedrook
umber Inches Cbserved Estimated Observed Estimated Character of Soil with Thicicnass in Inch.is
xample
0 72" 72" Black Too Snil 1?"• Cloy 15"• Ssnd 1~ G mrel 24"
tom" ~ q
/Cf y 7cS~ ~f
RECD tD Dn'A ca :I " 3 UC~ c:S
'M COMPLETE Of HER SIDE
I, the undersizned, hereby certify that the percolation tests reported on this form were made by me
or under by supe>-,rision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Adjninistrative Code, and that the data recorded and location of test holes are correct to
the best of my knc=sledge and belief.
TITLE C i t
(Type or Print)
REGISTRATION NO. or MASTER PL °13ER LICENSE No.
ADDRESS
DATE SIG;IATU S
MASTER PLf R"T3E'R PARING APPLI" yION
l~ rip
Sig,atura:~ License Number:
r- 2 RSW
h.
(To be ompleted by Issuing Agent)
Date of Application / 0 Fee Paid $ G'`~?
Permit Issued (de.t Permit Number
Agent (name) Yom(/ (t For:
~
Town, Village, City, County, etc.
(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 $10.00 and Copy (b) of the
Permit (yellow copy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health„
Do not write in space below - FOR DEPARI':TLNT USE ONLY
DATE RECEIVED ACCEPTED BY RETURNED _
(Initials) (Date) See Corres.)
FEE RECEIVED v VALID. NO. Lk ~ PEF&,IIT NO. 14
(Ye3 or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
h COFI'ENTS:
(
r
S.
P
4