HomeMy WebLinkAbout030-737-25-2201-SAN-1974-287 Plb 67 �"�'
� �~I
' ` �` State of Wisconsin and County
�'�'� Uniform Permit Application
'��- � for Private Domestic Sewage Systems Date fQ=3 I - 7Q..
` . County S j�1,9J��(�
State Permit .
Number �—� '� _ Permit Number�_8�
A.OWNER OF PR PERTY S � H Sm�N
Name: N Mailing Address:
�j ^ ,
____-��J-���L�-� .G7 S 4-835
B. LOCATION OF PREMISE WHERE SYSTEM WILL BE CONSTRUC ED,ALTERED R EXTENDED
LEGAL DESCRIPTION: Name One:
�Sec., Lot, Block, etc.) � ^t''� /Q�W. CITY � VILLAGE
/�/�l� � s(!/� .S�� �S � � TOWNSH IP
/ � v
- .
C.SEPTIC TANK CAPACITY a I s �, TAL���� REPLACEMfiNT ADDITION
♦
MATERIALS: Prefab Concrete Poure 'n Place teel Other ;No. of Tanks ��' �-
D.TYPE OF OCCUPANCY ^
One or Two Family Residence `� 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) ,�d�tL(�
F. EFFLUENT DtSPOSAL SYSTEM NEW EXTENSION ADDITION� REPLACEMENT
Seepage Trenches: No. Lin. Feet Trench Width Depth Number of Lines.
Seepage Bed: �ength :�Y � Width ��_ Depth u Tile Size � No. Lines-�3�
Seepage Pit: Inside diameter Liquid Depth
G. Percent of slope of land _.�_ % _ direction
H. Indicate Slope of Land &direction of slope on sketch 1. Tile Depth �'
P=RCOLATION TEST
Indicate Soil map number / And Soil Type � � � �
Hours Water Test Time Drop in Wa r �evel Inches Minutes i°
Test Depth Character of Soil Since Hole in Hole Interval Second to Next to Last To Fall ;'
Nunber Inches Thick ss in Inches 1st Wett ' Overnight in Minutes Last Period LastPeriod Period One Inch f
�
� /�(> u p�.� '� c) � (
�" G 1
ti � D .� 3 � i
� Y � -� Z � 3 � ��
� �
RECORD DATA FROM MINIMUM OF 3 TtST HOLES IN THE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED
SOIL BORINGS— Minimum 36" Below Pro osed Absor tion S stem ,
Boring Total Depth De h t Ground Water De t o Bedrock i
Number Inches Observed Estir�ated bserved Estimated Ch racter of Soil with Thi kness in Inches I
� � � l0 '� le����� � 4�ic ' �
i e � � ,k �
o � �� � u — I
� �
6 �!'
RECORD DATA FROM MINIMUM OF 3 BORE HC�LES IN TNE AREA IN WHICH THE SYSTEM IS TO BE INSTALLED
(C01AP�ETE OTHER SIDE1.
� F
4
�
Name of Owner ��R�1A�� SI N�SYYI'[�N�N County �-��_�.. State Permit No.
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 (3),Wisconsin Administrative Code,and that the data
recorded and lo �ion o t st holes are cor to the best of my knowledge and belief.
n � /
NAME �7� /.. �S �G -yeLU.I��sTITLE 2u
n (Type or Print) � � �����,
REGISTRATION NO. or MASTER PLUMBER UCENSE No. �— -�-
ADDRESS __
DATE OF TEST Q SI NATURE � �
� L
PERSON MAKING APP CATt N ' ADDRESS -�
; SIGNATURE
� r ,
� MASTER PLUMBER MA NG I STA LATIO ' I�ENSE NO. MP
� SIGNATURE , � MPRSW
Provide sketch below of system (Include direction and percent of slope and all applicable distances inctuding well location and
lot lines)
PLAN VIEW (Locate Percolation Test& Soil Bore Holes) .
��,
,
�
�
t
� � �
� (b ,
�� -
i..
. '
� ,
i �
D .. I
Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid.
Do not write in space below- FOR DEPARTMENT USE ONLY
Date of Application Fees Paid State �'�'� County ����
Permit tssued/Rejes�eel (date) QLT �1 �9�q-- Inspection Yes� No Date �� �7y
Issuing Agent Name _Q018�{ty�_�p�-1Rr2.�- ���QuTY Valid No. Date Rec'd. '
DIVISION OF HEALTH,P.i�: BOX 309, MADISON,W1. 53701 - REVISED 3-1-74
f
; Department of Zonin� and Sanitation
� 5awyer County
Inspection Report
Name of property �,�'.P���/iY�/fl9/�
Description NtJ�c�- �W �i,�- �'c. �s-�37,�- �Q7�,J
Owner Address
Builder Address
Ma,ster Plumber �, ,�iq,lCZ,�Js,C/ Address
Inspection
�) Private ( ) Public Property Sanitary Installation
Dwelling Privy
Violation Mobile home Setback - Lake
Garage Setback - Road
( ) Sanitary ( } Zoning Setback - Lot line
�y
�� �� �
� �
►�'
�
Discussed with Builder � ) Yes �C� No
Discussed with Plumber �) Yes ( No
Date of Inspection /Qr - � �`�
Signature of Officer �v�