HomeMy WebLinkAbout002-940-01-5218-SAN-1972-44405 ' c6� - at�
566-.27/ Anrt,IC..�i7'ZOIlI FOR SAWYER COU'VTi
� SkIJi�'�FY PFHI�IT
Q . App Lication #u`�_'_i Date "�' � ^
�' Fee of SZU,00 rt:.ceived _`��% ��•r_� . • ` � , 1 .ikr
Jate County Ci:erk '
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Application is here3� made for a Sa�oyer Cour,ty Sanitary
Permit for moric � be done cn the premiaes deacribed ez .�--
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O�Lr 2 A ress TeZephone.��
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The o f the -- Sec. T�n. R. ' . � 2.�8
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� Lot�_� BZocK Sub-division " ' " ����5 ��
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:✓ork contemplated To ve parformed by
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IDumber of Bedropma:. z tiumber of Eathrvom�! i__
DisFw�asher :"'' J Gar��e Grinder
Automatiq�Washer "��
Soil Descriptio» :������� �`,���
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Septie Tank Sia.e i��� gaZ. �
Seepaye Pit HeiSY�t �_�kDvameter ,�2
Seepage Trench Leng.n _� :% [Jidth __ Depth
Septic Tank. Permtit ,Y ' � _ I�
Percolation Test Forr,� PL& 43 attaehed "
Yes "Jo
ContempZated corrpletion date �"�/ ��
Appltieation Approved Pernit # �� ��
Sanitarian� ' ' �-� -- ) ----
Or�rier gent �aota�ieu Daae
Remarks
Final Inspe"ct,�n
sanitariar. �l/ �'�� '72
Omrcer/Agent tVotified. (Date1
Remarks �� .!' !d� .�s�,.. ne �i � �—��"�;
*'�* Se�er� originaZ and three copies ufith.*** �'-
fee of $Z0.00 to County Clerk
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Indicat� Tot size and shape , Zoeation of dwelling ( D> ; septic tank
(ST) � septic fietcl (SF) or seepage pit (SP ) and distarice oJ° anr�
portion of septie systerr from dwellingy weZZ anc� property Zine .
If propert�� Zies wit,'ain 50 feet of a Zake , river or a s �re �zm so
ind�� cate and sizow distance there from, .
If an� portion of the eontemptated eonstruetian wiZl Zie within
25 feet of du�elling, raeZZ_ septic tank , sep �tic fzeZd or seepage
pit of abbutting o�aner so indicatee
The urdersigned agrees that alZ �ork performed and equipment
instaZZed shaZZ be in accordance r�it?a the Sanitary Code of Sa�yer
Countz� and aZZ app Zicab Ze Zaws and reaulations o f t'ae State o f
Wisconsin and recommendations of t�e Saw�er Countr� Sanitarian ,
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Ow r9 ge SZgnature )
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Yliioonsin DeparLoent of Health and Sonial Ssi'vioae
. �- Division of Health
SEPTIC TANR PERMIT APPLICATION
TYPE OR USE BIACK INK - PLEASE PRINT
A, Oi1NER OF PAOPERTY ',
�7e�e �� � Addrese (S;r�st, City� 11p Cods) ..
� , � . /,.� , . .. .. .
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B, LOCATION OF PROPERTY iJlIERE SYST NILL BE CONSTHIICTED ALREREII OA EATENDED ��COUNTY
Cheak Onet 1 ��� - `�J
CITY VILLAGE LDGAL DESCRIPTION �nps�'"'� � (.�p ��� �.' �
TOWNSHIP � (Block� Lot, Seo.)�••.'—�"� /I.��. ` ,��s
. f �' f-
C, SS IACAL PERMIT REGUIRED FOR THIS NORK7 YES No � PERMIT N� PA
D, SEPTIC TANK CAPACITY ^ ' -�GALLONS NEH INSTALLARION REPLACFMENT_ ADDITION_�
IMTERIALSt PAEFAB CONCRETE POURED IN PLACY_�546EL�_ClfHER� �
N!lIDER OF TANKS TO BS INSTALLEDt �_
E. TYPE OF OCCOPANCY
Cheok Onet One or 7ko Fatni�y Residenae_�Commeraisl�_Industrial_OEhar_(Speoify)
Number of persom to be Accomnodated� Number of dedrooms�_
F, APPLICkNCES� ETCt Pood waste Crinder�YES NO Automatic Clothar Washer �YES NO
�ista�asher YES �,_NO Automatio Potato Peelar Y&5 NO
OTFiER (specif�� YES __170
G. MASTER PLUMBER NiAKING INSTALLAT YI
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Name� � j . Addrsssi �-r�/s_��. /.~ i. )_ _,-
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SZ�7NATURB OF APPLICAN1�i��� � � _ -� -
�`J'7'=^^'+l�Z GG-
� ,.- �oense Nu�ber� [�
ADDliESSs '�
H� (TO SH COI�LETED HY ISSUING AGSNl�
F r
Date of Applleation � 1 Fes Ps1d
Parm10 Issu�d (daLs) - � P�rmit Nueb�r
Ageni ��);.. - --- For� �,
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� , LpImJ.� llig�, o1Ly�. bouaEy� �to, epeeiry)
NOPBt 'fhe Applioation oannoL De oonaid�»d for Piling wrtil all of tha ebwe q�dlLlons ar�amrt�rsd
and ths f�s paid, Agents wlll foeward appllaatlon� Lhe fs�of=1.00 for eaoh sapEio teNc snd
the third oopy ot Lhe ps�it (osasry) to LM Division of H�alih. Cheolu enG money oM�rs �hould
b�mada psyebl�to ths Dlvielon of Health.
C�LETH OTHER SIDC
NANBs ` ��
COUNfYt
SEP7IC TANK PEHI1TT NUMBERt '
REPORT ON SOIL PERCOLP.?ION TEST '
AND SOIL BORINGS
TO
DIVISION OR HEALTN - Pll1MBING SECTI(87
P,o,BOX 309� Ihdison� Yis. 53701
Purtuan4 to H 62,20, Ni�, Administraviva Cod�
P 6 R C 0 L A T I 0 N T S S 7'
4EST DBPTH CHARACTER OF SOIL HOUqS SiATGR TE51 2If� DROP IN Y(AT R IdVfiL INCHES HINUT6S
M1ISBEA INCHES THICiCNESS IN INCHES SINCC HOLE IN HOL6 INfERVAL SECONJ '!0 E%7 TO LAST RO FALL
lst IiEPTED OVEANIGHT IN MINUTES LAST PEAIOD LAST PEAIOD PERI00 ONS INCH
E7CAMpLE
P - 0 36^ 70P SOIL 10^ CLAY 26" 25 YES OH NO 30 60
1 �/ .;.. .J�:U.,`3 � L �S`.'/ 's"'r} ,� I�
ry� . - ' ' :3 /l ` � - .. - , � f . (J
2
3 - ,, ; ; v ' i; :-; .,i:w,� �J U
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RECOAD DATA FROM lG.NIMUM OF 3 R%ST HOLLS
COI�UTC SIZE OF ABSORPTION AREA IN ACC03iD WI?N H 62.20 NIS. ADMiNISTHATION CODB.
S 0 I L �B 0 R I N G S - MINIMUM 36�� BELOW Pa0?OSEO ABSf,'�PPION SYSTIII
BORING TOTA6 UEPTH DEPTH TO GROUND NATER DEPTN TO BEOROCK
NUMBER INCF�S OBSERVEO ESTIIIATED OBSERYED ESTIMATm CHNRACTEP OF SOIL WITH ^.HIC(Q7E55 IN INCHCS
E%A!P
g • 0 n u K 0 OI � C / a, u u
1 p a' � �Y �-�7 . - .✓ �
_ 6
2 O ! , ,1 � � ' - �� .
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3 S , `� „ � l
RECOR➢ DATA FHOM MINSMIM 0
PYPE OF CCCUPANCYs
RESIDENCE: NUMi3EA OF BEDROOMS�_ OTHCFit (SPECIFY) NOlIDBR OP PSRSONS
FOOD NAST6 GRIHIIER: YES� N0�DISF6fA5l�Rs YES-�t�� NO,k� AUTOMATZC C{.01'fS5 NASf�Ra YES� NO
� 6FFLUENT DISPOSAL SYSPQ1t NE�l V E7CTINSION AODITION. REPLACF2�NT
TIIE SIZ� N0, LIN, FEEi��TRENCH WIDTFi1�DEPTt{�1MBCR OF LINES��
SEFPAGE BfiDt LENGTHL� HIDTH���DCPTH� TILF. SIZE� N0, LINES '
SEEPAGE PITt INSIDE DIAMETFA LIGUIU DE —�
I� the undersig�ed, hereby aertify tMS Lhe yercolation tests reported on thie Parm were made by me or under � super—
vislon in a000rd Rith the prooedures nnd method specified Sn Chapter H 62,20 (3 ), Hieeoneia Adminiatrative Code� and
that the data recorded and loastion of test holee are correoL to ths best of Qy laiowladge and belief. .
NAME �.��:-._ /��' � 'i/ . - TITIE ' � r- .� �
� � PE or PR1NT �� w / /
REGISTRATION N0, pA MASTER LUifBEP LICENSB NO,�T��
ADDRESS L • �� / � ,./��
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DATC I ^ ��,� SIGNATURC � ' (r .
0 NOT i1AITT IN SPA C A DEPARTHBNt ONLY
DATE IYED ACCEMED HY AEiVANEC
PEE RECEIVED YALID N0,
REYIENED Hy P�a �•
APPROVCD DA,�,j
INITIAIS 1Ti5 OR NO
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