HomeMy WebLinkAbout032-538-04-4101-SAN-1974-247 Plb 67 r�'��� . .
i State of Wisconsin and County
��'� �� Uniform Permit Application Date
�:. for Private Domestic Sewage Systems ����-,�
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State Permit ' '
Number �� PermitNumber.4=Z4�
A.OWNER OF PROPERTV
Name: w�LL�C� W�Qg Maiting Address:
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B.LOCAT�ON OF PREMISE WHERE SYSTEM WILL BE CONSTRUCTED,ALTEbLR�O EXTENDED L�00�
LEGAL DESCRIPTION: LOT � Name One:
(Sec.,Lot,Block,etc.) � �� •������ TOWNSH�pLLAGE
��-�_�' _ . /3 g �/S a W
C.SEPTIC TANK CAPACITY sp Gallons NEW INSTALLATION __1�_ REPLACEMENT � ADDITION
MATERIALS:Prefab Concret� Poured in Place Steel —�Other ;No.of Tanks _�_—_
D.TYPE OF OCCUPANCY
One or Two Family Residence �LN � �No.of Bedrooms � _
Commercial Industrial Other No.of Persons to be Accommodated �
� (specify)
E.APPLIANCES,ETC.: Food Waste Grinder YES--�NO Automatic Clothes Washer YES NO
� Dishwasher YES�NO Other(Specify) _
F.EFFLUENT DISPOSAL SYSTEM NEW�— EXTENSION ADDITION REPLACEMENT —_
Seepage Trenches:No.Lin.Feet Trench Width Depth Number of Li�es—
� � �
Seepage Bed:l�ength �/.� Width ��— Depth --3 Tile Size u�� No.Lines _
. Seepage Pit:Inside diameter Liquid Depth �
G.Percent of slope of la�d �L% direction
H.Indicate Slope of Land&direction of slope on sketch . I.Tile Depth
PERCOLATION TEST
Indicate Soil map number � And Soil Type
Hours Water Test Time Drop in Water Level Inches Minutes
Test Depth Character of Soil Since Hole in Hole Interval Second to Next to Last To Fall
Nunber Inches Thickness in Inches 1st Wetted Overnight in Minutes Last Period last Period Period One Inch
If l O O ,
%
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'/ Q ,I� �Y �
RECORD DATA FROM MINIMUM OF 3 TEST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTA�LED
SOIL BORINGS—Minimum 36"Below Pro sed Absor tion S_ystem
Boring Total Depth De th t r n Wa De dr k
Nurber Inches Observed stimated bserved Estimated Character of Soil with Thickness in Inches
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1, � •i . � �� .
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RECORD DATA FROM MINIMUM OF 3 BORE HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED ;��-�s
(COMPLETE QTHER SIDE) " ;
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Name of Owner � L�iV " County ��� t�"'�f State Permit No.�U�7
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PERCOLATION TESTS � �
I, the undersigned, hereby certify that the Percolation Tests reported on this form were made by me or under my supervision in
accord with the procedures and method specified in Section H 62.20 (31,Wisconsin Administrative Code,and that the data
recorded and location of test ho�re correct to the best of my knowledge and belief.
NAME �L/;��y/q/ �rJ 4 IJ� O TITLE
(Typa or Printl C�
REGISTRATION NO. / or MASTEfi PLUMBER LICENSE No. �7��� /
ADDRESS G�.) i�N T2. F�
DATE OF TEST �4'� J — 7 r SIGNATURE � //����
PERSON MAKING APPLICAT/JION ��� � Q�-�—�•�-�� ADDRESS
SIGNATURE !,�'-d�'�/L��'N �f'L6� . ,S r.-��
MASTER PLUMBER MAKING NSTALLATION ��.� LICENSE NO. MP
SIGNATURE MPRSVµf� l2l
Provide sketch below of system (Include direction and percent af slope and ail applicable distances including well location and
lot lines) �
PLAN VIEW (Locate Percolation Test& Soil Bore Holes)
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� Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. �
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� Do not write in space below— FOR DEPARTMENT USE ONLY
- Date of Application Pees Paid State �•�O County ��.��
Permit Issued/Rejected (date��-� 1� �q7Q- Inspection Yes� No _ Date ��'�s"7� .
Issuing Agent Name K0��2�.1 K�PtlA'et- OEPUzY Valid No. Date Rec'd.
DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI. 53701 — REVISED 3-1•74
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Department of Zonin� and Sanitation
Sawyer County
Inspection Report
Name of property ��«E ��-$a
Description l,ar � - l�k y'f- S,��i/- S,Cc. / �3�/J - /`��SW
Owner Address
Builder Address
Master Plumber vo,,� %,s�eyPsv�J Address
Inspection
� Private ( ) Public Property Sanitary Installation
Dwelling Privy
Violation Mobile home Setback - Lake
Garage Setback - Road
( ) Sanitary ( ) Zoning Setback - Lot line
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Discussed with Builder � Yes f'� No
Discussed with Plumber Yes j ) No
Date of Inspection /D� �15� 9`�
5ignature of Officer �-�-� �-� ��