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° Wisconsin Dopartment or Health and Social Servioes
Pin. #67 10/69
Division of Health
PEiMT APPLICATION
for
PRIVATE DOaESTIC SEWAGE SYSTEMS %r
NZ N 3
A. 94NFR OF PROPE,%'TY TYPE OR USE BLACK INK
Fume - / Address (Street, City, Zip Code)
B. LOCATIOt1 0OF PP VJPERTY WP F SYSTF WILL BE CO'r,S CriUC T ED, AL'_///FD OR EXTENDED C ounty
Cneo'c One;
CITY VILLAGE LEGAL DESCRIPTION; J
TOWNSHIP
C. IS LOCAL PEr`i IT REQUIRED FOR THIS FDRn? \ YES NO PEFVIT NUT. ER
D. SEPTIC TANK CAPACITY J. Gallon > NEW INSTALLATI3' i. REPLACEP/,E*NT ADDITION
MATERIALS; Prefab Concrete Poured in Place Steel Other
Ni1tiC3ER OF TANKS TO BE I'QSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or No Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Acco-,iodated Number of Bedrooms
F. APPLIANCES, ETCs Food Waste Grinder YES f. NO Automatic Clothes Washer YES NO
DisTwasher YES NO Automatic Potato Peeler YES } NO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW k, EXTENSION ADDITION REPLACEiWNT
Tile Size j/.. No.Lin.Feet 0 { Trench Width " _ Depth Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines
Seepage Pits Inside 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 Drop in Water Level Inches Ninates
Number Inches II Thickness in Inches Since Hole in Holt Interval Second to Ne t to Last ^o Fall
13t Wetted Cverni?ht ! in Minutes Last PerLast Perio Period Qne Inch
Example
P- 0 3611 To Soil 10" Clav 2611 25 es or no 30 1/2 1/2- 1/2 60
Cv?D DAT:S FROM MINIMUM OF 3 TEST FOLKS
Compute size of absorption area in accord with H 62.20 Wis. Adninistre avn'Ccde.
S 0 I L B O R I N G S- Minimum 36" Below Proo3sed Abso";tion System
oring Total Depth Depth to Ground Water Depth to Bedrock
umber Inches Cbserved Estimated Observed Estimated Charaetar o:" Soil with Thickness in Inches j
Xample -
0 72" 72" -Viti Y 61aok To Soil 12" ;_Clay 18"• Sand 18", Gravel 24"
6
7 it
.rl S. 4 r J X14 /il , i r
7c 0
RECORD DATA FROM MINI-IJM OF 3 HORrE HOLES
COMPLETE OTHER SIDE
f
1
I, the undersi;ned, hereby certify that the percolation tests reaortad on this form were made by me
or under by supervision in accord with the procedures ,,,id method specified in Chapter H 62.20 (3),
Wisconsin Administrative Coda, and that the data recorded and location of test 1»les are correct to
the best of my knowledga and belief.
NAIL TITLE ? o
(Type or Print)
REGISTRATION NO. or MASTER PL;.T3E.R LICENSE No.
ADDRESS
DATE }l r SLGNATU:1f'
MASTER PLi','Dc:R MAKING AP?LICATICN
Signatu...;~~~__-~> MP
a; - - License er: px.
Np ~tS n ' /
(To to Completed by Issuing Agezat)
Date of Application Fee Paid $ ?y
Permit Issued (date) Permit Number
Agent (name) , For:
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 'oe made
payable to the Division of Health.
Do not write in space below - FOR DEPAcTICNT USE ONLY -yn~g
DATE RECEIVED ACCEPTED BY RETU R.NED
(Initials) (Date) (See Corres.)
I f~ GJ
FEE RECEIVED VALID. NO. PERT-UT NO.
(Ye3 or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
CO TIENTS:
I
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