HomeMy WebLinkAbout020-1045-40-000
Wisconsin Department of Health and Social SAr•vices
Plb. #67 10/69 Division of Health
PERMIT APPLICATION
for ,
PRIV,TE D0+"IESTIC SEWAGE SYST1913i ~ V /6~~-
l'' INC~
A. OWNER OF PROPEtM TYPE OR USE BLACK INK
Name Address (Street, City, Zip :ode)
County
B. LOCATION OF PROPERTY WF'RE SYSTKM WILL BE CONSTRUCTED, ALTERED 1R EXTENDED
Check One: 11 c1 I• 5 Lri *l 1/tI r
CI'T'Y VILL%GE LEGAL DE CRIPTION: 1- C _ ! ( L
TOWNSHIP
C. IS LOCAL PERMIT REBUIRED FOR THIS WORK? YES - NO PEFVIT NUMBER
D. SEPTIC TANK CAPACITY l,4- ~ Gallons NEW INSTALLATION REPLACEMENT ADDITION .
MATERIALS: Prefab Concrete --L Poured in Place Steel Other
MM ER OF TANKS TO BE I'ISTALLED:
E. TYPE OF OCCUPANCY ,
Check One: One or Two Family Residence: Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated _ Number of Bedrooms 1
F. APPLIANCES, ETC: Food Waste Grinder -2s-YES NO Automatic, Clothes Washer YES NO
Dis:raasher YES = NO Automatic Potato Peeler YES `n NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTE"T NEW EXTENSION ADDITION REPLACEMENT
Tile Size NO.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length _ Width Depth Tile Size No. Lines
j Seepage Pitt Inside diameter *9 r Liquid Depth •-i"~
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches xinutgs
Number Inches Thickness in Inches Since Hole in Hole !Interval Second to Next to Last Po Fall
1st Wetted I Overni^ht Lin Minutes Last Period) Last Per-I0 Period One Inch
Example 1 -7------'- _
P- 0 3611 To Soil 10" Clav 26" 25 es or no i 30 112 1/2- __1/2 60
RECORD DATA FRC 4 MiNIiITYI OF 3 TEST H,-LKS
Compute size of absorption arer in acoord with H 62.20 Wis. Acministre ive Coda.
S 0 I L B 0 R I N G_S_- Minimum 36" Below Proposed Absorption S st ~m
Boring Total Depth Depth to Ground Water Depth to ~Bearcck
umber Inch's Observed Estimrted Observed Estimated Character of Soil with Thickness in Inches i
xample
- 0 72" 7211 Black Too Soil 12"• Clay 18"• Sand 1211• Gravel 24"
t J
'31 V A, f) .0 1, 2
RECORD DATA FROM MI`MUM OF 3 BORE H..OLES
COMPLETE OTHER SIDE
I, the undersigned, hereby certify that the percolation tests reportod on this form were made by me
or under by supervision 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 my knowledge and belief.
r{
NAME fit.' cl 0 1XIq -TITLE i 't.'J:_v?
(TypS' o}-Y~ r print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No.
ADDRESS X/0 L'
DATE 2, SIGNATURE
MASTER PLIJIt3t~R M4KING APO" , CATION
i
r-/MP
Signature: ~i~'' License Number;
IMP RSW
(To be Completed by Issuing Agent)
Date of Application 1~! /fir Fee Paid
Permit Issued (dat ) / ! G Permit Number
Agent (name) Forz-1
Town, Village, City; County, etc.
(Specify)
Notes 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 DEPARTSM' USE ONLY
r
DATE RECEIVED ACCEPTED BY 1-~ RETURNED
(Initials) / y (Date) See Corres.
FEE RECEIVED VALID. NO. O 3~ PERMIT NO. ~J
(Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
C=WNTS:
r