HomeMy WebLinkAbout020-1081-20-000 (2)
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Wisconsin Department of Health and Social Servioea
f?b, F57 3/70 Division of Health
SEPTIC TANK PEP-MIT APPLICATION
TYPE or USE BLACK It4-X 7 e / • i` a vV
A. ONNER OF PROPERTY
Name Address (Street, City, Zip Ccd>e)
,y
B. LOCATION OF PROPERTY Wi'<< SYSi 1 WILL BE COP1STRlCTF.D,ALTER OR FXTE2D D COUNTY
Chec% One: -
CITY VILLAGE LEGAL DESCRIPTION
`r TOWNSHIP
/
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO % v>`~ ;L PERMIT NU!'B_KJ,'
D. SEPTIC TANK CAPACITY i`: ! Gallons NEW INSTALLATION RaPLACT_ N1 ADDITION
MATERIALS: Prefab Concrete r i Poured in Place Steel Other
NU`BER OF TANXS TO BE I iSTALLz-D: f _
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence ~ Coc~_7ercial Industrial Other
~ (Spew'.ri
Number of Persons to be Accommodated Number of dedreoMs
F. APPLIANCES, ETC: Food Waste Grinder YES ! No Automatic Clothes Washer Yi:S NO
Dish>r3sher YES f NO Autouatho Potatu Paclar _ YES_ xO
Other (Specify)
G. MASTER PLUiWER MAXLN;G INSTALLATIGN
Address: License i;u*ber:
_2 tl
Signature of Applicants ✓ i' tie RSW
Address: J J^f fi" 1~' r
H• (To,be Completed by Issuirg Agent)
Date of Application f r c~ l L' Fee Pstd $ t
Permit Issued (Ote)✓
/ ~Permit N*u-b/er
Agent (Name) Fort C
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of t`.a .-_vuva quc2,tinns are answered and the
fee paid. Agents will forward application, the fee of 31.00 for each s.eptie tanx and the third copy
of the permit (canary, to the Division of Health. Checks ant money orb-0rs shovid be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE-ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Corr--s.)
j FEE RECEIVED i VALID. No. PERMIT NO.
11 (Yes or No
REVI£:iED B'd APPROVED DATE.
(Initials)
Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PSR,'iIT NO.
f'
R: P 0 R? O N S O I L P Z R C 0 L A T I 0 N ? E S T
AHD 3 0I L ' a" v"RI N G S
TO
DIVISION 0' !=LTH - PLUIBIN ; SRCTIc1'iY
P.O.Box309, t:dison, Wis, 5:3701
Pursuant to H 62.20, Otis. Adnai-nlstrativ-j Coda
P E R C O L A T I O N T E S?
,eat ump:n Charactar cf Sail J25 ter Teri'; TLaa Drain V"ter Level Inchas [mutes
Nuer Inohas ?hin~ness in Irahas SBole Intl real Second to Ne t-7---T- I~.st i?o Fell
1niLht in 1-Inuta.3 La-,+t P^7 iofl L st Period!n-riod ?nx ; sc':
Example _P 0 36" ico Soil 10'x, C1 26" or Na 30 11-2 i 2~112 60
7DZ
RECORD DATA FROM ME4L1UM OF 13 -DST SOLES
Compute s-'ze of absorption aroa in accord with H 62.20 Wis. Administrative Code.
SOIL BORINGS 'Mini.us 36" Bel>:°s P.-a- osad Absorption _ Sya'::-~
Boriras; ?otal Depth Dcpth to Gr u. d b?a De-pt:imato Bedroc
Number inches Cbsarv:~d N5ti ited~ Ooserv d Esti Character of Soil with Th'_o-sness in In,hes
Eazp~a
BOO 72" 72" black Top Sv11 12t1{ C1=. ^+'_W `u"• G:-avel 24"
P-C,7PD DATA FROiCa 11A III
3~B0c N4r,n
,
Ye~E OF OCCUPA~iC'3,
R:;SIDi29CE: Number of Bedrooms OTHZR: S ecif
_ (p Number of Persons
CI'D WASTE GUNDER: Yes No Disharashera Yes - No X1~~ Arbo tic Clothos Wasazr; Yes ~ No
FFUIEN DI.S?OSAL SYSMs NLd EXTENSION ADDITION REPLA a-'JENT
Tile Sizs t _ Na,Lin. Faet,/ Trench Width 5 Depth j' Number of Liras
Seepage Bed: Length Width Depth Tile Size No. Liras
Seepage Pit: Inside Diameter Liquid Depth
I, the undersigned, hereby oertif, that the percolation tests raported ot. thls form ware made by me or under my super-
vision in accord with the.procedures and method specified in Chapter H 62.20 (13), Wiaoonsin Adainistrativa 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
REGISTRATION NO. or MASTER PLUMBER LICENSE NO, j
ADDRESS
DATE l C? / S IGNATURS 4"-/ /
N7R20- 191N. 257
SEE PAGE 39 T 29
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