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Nisooncsin Department of Health and Social Services
Plb.67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION ti
TYPE or USE BL.•.CK INK
A. EAS 2ER F PRO?,rRTY
Address (Street, city, Zip Codo)
B. JdOCATION OF_P_R_O?ERT_YW.y.RE SYSTEM WILL BE CONSTRUCTED, ALTEpEL_OR EXTENDED COUNTY. ! 1
Check Ones ~l f
CITY VILLAGE LEu""AL DESCRIPTION~J~YPL -r
C. IS LOCAL PE211IT REuUIRED FOR THIS 'W'ORK? YES NO r4 ; . J PERMIT NUMBER
D. SEPTIC TANK CAPACITY " Gallons NEW INSTALLATION t' REPLACEtSNT ADDITION
MATERIALS: Prefab Concrete i' Poured in Place Steel Other
NU`IBER OF TANS TO BE INSTAL1.vl: `
E. TYPE OF OCC
Check One(\`' Cn eor Two Family Residence / Commercial Industrial Other
Specify)
Number of Persons to be Accoazaod ted- Number of Bedrooms
r.
F. APPLIANI:.. rS, ETC: Food Waste Grinder YES e' ' NO Automatic Clothes Washer YES NO
` __T...
DisraTasher YES NO Automatic Potato Peeler YES NO
Other (Specify) '
G. MASTLR PLjrBER MAKING INSTALLATION
Name: rx_. -ff ! f';'` 411 ,r'•; Address] License Number:
/I hP
7 r
Signature of Applicant: !/l, ^ MP RSW ~
J i
Address:
~
be Completed by Issuing Agent)
Date of Application 1,7" Fee Paid ;
Permit Issued (date) Permit Number %
(Name) ti _~"1 For:, Agent
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 for-ard application, the fee of $1.00 for each septic tank and the third copy
of the permit (canary) 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 DEPARTMENT USE ONLY
r-I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Torres.)
i
FEE RECEIVED VALID. No. 3 _`5'a PERMIT NO. f/ 7
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
r
SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P I R C 0 L A T I 0 N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLI,:Slll;. SF;CTIN2
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.209 Wis. Administrative Code
P B R C 0 L A T I 0 N T T S T
Test Depth a-Arraoter of Soil Hours Water Teat TL,!) Drop in tiFater Level Inches at as
Number Irohos Thiokna3s in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnivht in Minutes Last Period Last Period Period Ora, Inch
Example
P - 0 3611 To Soil 10" (<Clay 26" 25 Yes or No 30 1 2 I L2 112 ~ 60
r
' RECORD DATA FROM MINLMUM OF 3 ;s.ST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minims 3611 Belo- reposed Absorption S stain
Boring Total Depth Depth to Ground Water Dap - th to Bedrock
Number Inches Cb3ervod Estim tad Observed Estir.:aed Character of 5ai1 with Thiosnsss in Inches
Example
B - 0 72" 72" Black To Soil 12" Cla, 1811; Send 181e; Gravel 2411
~ ~ ~ , ! f 1. L L i, C • _ % ` 3 t l ~ ^ 'i
IL?
RECORD DATA FROM MINIMUi`1 OF 3 BORE HOL S
TYPE OF OCCUPANCY: _
RESIDENCE: Number of Bedrooms 0THERs (Specify) Number of Persons
FOOD WASTE GR L'tDE.4s Yes No Dishwashers Yes ,X No Automatic Clothes Washers Yes No
FFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width JI- Depth Number of Lines
Seepage Bed: Length Width Depth's Tile Size No. Lines .
Seepage Pit: Inside Diameter Liquid Depth
Is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME TITLE
(Type or Print
/•r. f
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
J :ADDRESS T ? J/'C
rt / 7 _SIGNATURE
DATE /
T !r
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o said CH. Lot 3 go N 89x 510 it f°C o 422.0 feet;
yyam~0115 feet ivy
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at the z1 t'im. v S ' a of t zd' _~'s north-
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along the south line of a psx vo
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