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Wisconsin Department of Health amn Soois.l Servioes
Plb. #67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BUCK INK
A. 0411ER OF PROPERTY
Nara Address (Street, City, Zip Codas)
B. LOCATION OF PROPERTY WIT-ERE SYSTEM WILL BE CONS'iRLCTE•D ALTERED OR EXTEMIED COUNTY
Check One:
_ CITY VILLAGE LEGAL DESCRIPTION
TOhRiSHIP~ ~ ~
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? /a YES NO 0'/ % PERMIT NUMBER
D. SEPTIC TANK CAPACITY L ('Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NLT%MER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Cheek One: One or Two Family Residence ~ Cosra:ercial Industrial Other
T-- Specify)
Number of Persons to be Accorrmodated Number of Badrooms
F. APPLIANCES, ETC: Food Waste Grinder YES t NO Automatic Clothes Washer X YES NO
Dishwasher _ YES! NO Automatic Potato Peeler YES Y' NO
Other (Specify)
G. MASTER PU73FR ?TAXING INSTALLATION
,/r l
Name: 7 r /n ~ 7 Address: _l License Numbers
MP
RSW
Signature of Applicant:
Address:
H. (TQ be Completed by Issuing; Agent)
Date of Application Fee Paid $
Permit Issued (date)' ~A 1-7 P Permit Number
Agent (Name) No 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 wial forward application, the fee of ;1.OG for each septic tanx and the third oop.
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
- 7✓1 '
1. DATE RECEIVED _ ~ - ACCEPTED BY _~Il RETURNED
(Initials) (Date) See Corres.,)
FEE RECEIVED VALID. No.
es or Ho PERMIT NO.
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
y 5
R Y P 0 R T O N S O I L P E R C O L A T I O N T E S T
A N D S O I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLU-0ING SEM61
P.O.Box 309, Kdison, Wis. 53701
Pursuant to H 62.20, Wis. A&inistrativa Code
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Tice Drop in i2ter Level Inches hinut
Number Inches Thiolmess in Inohas Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overni^ht in Minutes Last Pariod~Last Period Period Or,e Inch
Example y
P - 0 3611 Too Soil 10" Cla 26" 25 Yes or No 30 1 2 1 2 1L2 60
RECORD DATA FROM M LiDTJM OF 3 TEST 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- Minimum 36t1_Bel" Pro2osed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedroc;;
Number Inohas Chserved Estir,.%ted Obaerved EstiTa'ced Character of Soil with Thickness in Inches
Example
B - O 721f 72" Black To Soil 12" Cla L8111 Sand 16". Gravel 2411
RECORD DATA FROM MINLM M OF 3 BORE HOLM
YPE OF O'CUPANCYt
RESIDENGEt Number of Bedromas OTHER: (Specify) Number of Persons
FOOD WASTE GRINDERt Yes No Dlshlashert Yes No Automatic Clothes Washsrt Yes ✓1 No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No. Lin. Feet-z l_j Trench Width Depth .J~ Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
J Seepage Pitt Inside Diameter Liquid Depth
Is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under nay super-
vision in accord with the procedures and method specified in Chapter H 02.20 (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 / f
REGISTRATION NO. or MASTER PLLMBER LICENSE NO. ~ll_r i
ADDRESS 1. = 1> L..' i I 44n
DATE ~ - J, ~ ~G~ SIGNATURE(" '11,
pi lop"llmigi
s
Li Li Li LJ LA LA L-1 L-1
44I
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