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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 408204 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Miller, Dan I Star Prairie Township 038 - 1154 - 20-000
CST BM Elev: Insp. BM Elev: BM Descript'
1001
TAN INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
m 0 �`�; -3-�� 125 3.51 103, (bb'
Dosing' M
1 2.23 101.
Aeration BI g. ewer • d3 - . -7
Holding _ St/Ht Inlet O
c�
TANK SETBACK INFORMATION St/Ht Outlet (m . 3 ��• Z 1
TANK TO P/L ELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , -qs- Dt Bottom �
Dosing Header /Man.
Aeration Dist. Pipe � v �� / Iq-9 t
Holding / Bot. System I
Z , iD 3 57
PUMP /SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
Model Nulller V 7'
TDH Lift riction System Head TDH Ft
Forcemain Le Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width ! Length No. Of Trenc,►�gs PIT DIMENSIONS No. Of Pits inside Dia. Liquid Depth
DIMENSIONS q / ��
SETBACK SYSTEM TO P/L 6 BLDG IWELL LAKE /STRE M LEAC IN
INFORMATION
Ty p f System: 1 p pp CHAMB OR T ✓ i"t Y
�o sv / 5f0� of IT Model Number: �l
DISTRIBUTION SYSTEM (�- �.OG
Header /Manifold Distribution / x Hole Size x Hole S Vent to Air Intake
/ h Pipe(s) / 17 It ! //
Length Dia_ Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center >D Bed/Trench Edges Topsoil -; N Yes ` ' No
/ / Yes I _J o
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: -/ 3 / i - Inspection #2:
Location: 1303 22� a Ne w Rdchmond, WI54017 (NW 1/4 NW 1/4 13 T31N R18W) Prairie Rich Lot 2 Parcel No: 13.31.18.706
1.) Alt BM Description= S�cl�rr� �Y')l LiJC1CQLJ r Iil.Q t� 1(Gi.Q,( _ {ro
2.) Bldg sewer length = Qom,` S Y�S
- amount of cover = l y s
J
Plan revision Required? Yes _ No
Use other side for additional information 1,_� - ,
SBD -6710 (R.3/97) Date Insepcto s Signature Cert. No.
I
Soft need DmAdmp Dwomem CMDRY ��
201 W. W Ara.. P.O. Box 7162 iX
III 1 n Mmdatoo. W1 S370r1 -'7162 Sire Addan � —
3 Z
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in accord vle Coaaat 8321. Wit. Adm. Code. ierawd I I 1 7011 w* 0 Cheek if levision
be and tar 815. 1 _
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Pity Owmr•s Mace Pand Number
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Cary. Rate Zip Code Lot Number Block NX 1�
SWAMsics Name CSM Number
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Pbtaiit Number Dfse i:,uad
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44 g Naa -Pa�rod b4maad 210 Ma=d 47 0 Sand FDW 50 0 Cocoucled Wedaad
22 Pteswrixod b*lisonod 410 Tack 48 0 Mm& Past 510 Drip Lane
43 0 M 3mft 46 0 AcroW Ttest memet UM 49 0 Radmalsdol 30 0 O mer
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C ST. CF?OIX C.OUN Y
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of
FILE INFORMATION SYSTEM SPECIFICATIONS
Ownert"N `� Septic Tank Capacity ( g 13 NA
Permit # 12 2-0 Septic Tank Manufacturer
QS ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model A lro-D ❑ NA
Number of Public Facility Units — D NA Pump Tank Capacity a l VNA
Estimated flow (average) po gal/day Pump Tank Manufacturer NA
Design flow (peak), (Estimated x 1.5) L gai/day Pump Manufacturer EK
Soil Application Rate , 7 g auda w Pump Model t%NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit #WA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (SOD.) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids ITSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BODJ 530 mg /L In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids iTSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510` cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other.
Other: ❑ NA Other
* Values typical for domestic wastewater and septic tarn effluent. Other' IQ NA
MAINTENANCE SCHEDULE •
Service Event Service Frequency
Inspect condition of tank(s) At least once every: month(s) (Maximum 3 years) 0 NA
`ICI
3 ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
mortthisl (Ma
Inspect dispersal cell(s) At least once every: C! itlamm 3 years) ❑ NA
year(s)
Clean effluent filter At least once every: --2_ El monthisl ❑ NA years)
Inspect pump, pump controls & alarm At least once every: 0 mo Y antf) r— -
❑ month(s) WNA
Flush laterals and pressure test At least once every: ❑ year(s)
Oa ❑ month(s) NA
At least once every: ❑ year(s)
Other: RNA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following i'oenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal ceUis) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third 1Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event..
GMW 14/011
TART UP AND OPERATION pa" of
For new construction, prior go use of the POWTS check treatment tanks) for the presence of painting products or other chemical
• that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the content
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power win
discharged to the dispersal con(sl in one large dose, overload' the ceil(sl and Rom is restored the excess wastewater rge b, effluent. To avoid this situation have the contents
of the a rresult the backup or surface discharge o
power to the effluent normal Pump o' contact a Plumb Pump tank removed by a Septage Servicing Operator prio to restorinf
Plumber or POWTS Maintainer to assist in manually operating the pump controls tc
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the arw
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; most scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails andlor is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
+ All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing operator.
Aerator.
• After pumping. all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be Protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the rsplacannent area will
result in the need for a new soil and site evaluation to establish a suitable replacement area, Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Baring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name
Oil h QrS Name
Phone 5 /3-S Phone
SEPTAGE SERVICING OPERATOR (PUMPER, LOCAL REGULATORY AUTHORITY
Name Name
I L
Phone
Phone `T is
This documerrt was drafted in compliance with chapter Comm 83.22(2 1(b)(1 )(dM(f) and 83.54(1). (2) & (3), Wisconsin Administrative Code.
r ST. CROIX COUNTY;ZONING „OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the co.,� �� \� P � residence located at:
LC) 1/9 Seca - L3 — , T__ / N W. Town of
_ u I rl-f Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced a ao8 1
Did flow back occur.from absorption system? Yes / (if no, skip
next line)
Approximate volume or length of-time: gallons minutes
Capacity: 0 C) C)
Construction: Prefab Concrete steel Other
Manufacurer (if known):
Age of Tan f known):
(Signature) (Name) Please Print
m�PS 'e� zz�s3�
(Title)' (License Number)
O 2
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - --- - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, Adm.. Code (except for
inspection op n g over outlet baffle).
�+�� b�'�'' Signature D53�
Name
/MPRS �-�
5/88
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Lmu
Mailing Address 5Q � Alel J
Property Address 341Y9t,
(Verification required from Planning Department for new construction)
/I 7q DLo
City /State /& &AMe A) Parcel Identification Number 3 �
LEGAL DESCRIPTION
Property Location A W V., N 0 V., Sec. � a T_3-�N -Rj!�'—W, Town of
Subdivision , Lot # _ d�_.
Certified Survey Map # . Volume , Page # _
Warranty Deed # j ±J Q D,&S , Volume Page #
Spec house O yes K] no Lot lines identifiable [('yes 0 no
SYSTEM MAINTENANCE
Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance-
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the ftimetion of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master piumber,lourneymanplumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe-, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
DOCUMENT NO. - - j � STATE BAIT dj" WISCOACSlN FORT[ 1 — t88iir rai siicaicssm'ie iow wrcaioake nas�
' WARRANTY DEED !
- �470 .. ►5 REGISTER'S OFFICE
..
ST. CR01X CO., W1
This Deed made bctween ........................ .... .. .. .. •- ••- •- •--- ......•...
� Steven D. .ConetaRt._. ells ..R e_heI.. -9 .... C Reedfor Re cor d
.. wile. ...... . ............... .. ..... ;
., 1:15 P M �.
and.... - Daniel B. -, Mille ;.. nd..I�?ulr.3a..A- 11i1Lex..- husband.... - - - - -- { /� /�
and wife, . marit4]..survivorship. -pro perty •-- ................. V (.c'�,{,�
............... ................_._.-- --- -•- -I- ._..- ._--- --- --- - - - --- -• Grantee,
yVi$neSSeth, That the said Grantor, for s valuable consideration-__ I
- - - -- -. ................. ...... . .. •........-- - -.... i pR �R;. ;0 ._�_�— . _�_�.�:
conveys to Grantee the fo ;luwing described real estate is __._5t, -- Croix.,__ -_ -,
County, State of Wisconsin: f
i
l
Tax Parcel No:.._ _..__— ------ --
Lot 2, Prairie Rich Subdivision in the Town of Star Prairie,
St. Croix County, Wisconsin.
j;
}
6
is
f;
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- This ... ........ --- homestead property.
�S tie) (is not)
i!
}' Together with all and sing the hereditaments and appurtenances thereunto belonging;
t
Steven D. Consant and Rachel R. Constant -
And. .. .. ...........................
`l• warrants that the t(tie is good, indefeasible in fee simple and free and clear of encumbrances except
i
and will warrant and defend the same -
31st Ma
Datedthis ................. ...... _---------- -• - - -- .... -. day of _........_ ...y. ........_......
l;
1
............... ........(SEAL) 46 G I t - ...( SEAL) ..... .......... ...... .. •-..._.. - -- - X "'' ant
.--....-----• .... ......................._...• - `.
...... • - -- - --
.....
.._ ........ - .....(SE
! (SEAL)
------ •--- ._.......__.- .......... . - - -- _ _. - Constant:
{,
AUTSBNTICATIOfiT ACH11T(1WLEDOMBNZ
}! $ignatare(s) .._ STATE OF WISCONSIN
1: aa.
�? ......•- • .. ............. ....... ............................. -- .S t : _.. Croix ..__..•
-- • County. E s t
' authenticated this ........ day of ............... , 19.. Personal) canoe before we th' day of
ay lg �1 the above naaxd
.......................
......• .........................•----•--••----• .._............_.....__........ Steven D. Constant and Rachel_ iL.
------ • ....... ...... ................. ......._..........
Constant husband and SriE--. ____...
TITLE: MEMBER STATE BAR OF WISCONSIN ................. ••..--- ............... -...... ---•_- ....... ...................
i, (If not . . .......... ......
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AS BUILT PLAN OF SANITARY SYSTEM
�L�he
IV_ COUNTY
SEPTIC TANK PERMIT #
ADDRESS _� n_- - - - - - ZIP - - -
LOCATION OF SYSTEM: d '/„ Wj. of Section aTownZLN, RANGE + W
Gov. Lot , Lot # :2i Subdivis - on
PLAN VI jjkW
Distances & Dimensions to meet Requirements of H62.20(1)(d)(2)
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
- ------------- ~ -------------------------
i
i
t
i
k
---------------------------------------
SEPTIC TANK: Concrete r..- /Steel Mfgr. iU6,r Z S Depth to manhole 2
SOIL ABSORPTION SYSTEMM: Drywell Depth Inside Dia. Depth Below Inlet
TRENCHES, No. of Width _ Length Area to Pipe
BED, No. of Lines Z Width/7' Length j7_ ' Area Depth to Pipe Z j �
AGGREGATE,. Inches Area Required /5 Q AREA AS BUilt lv �SCa
r
DISCLAIMER: The inspection of this system by Polk County does not imply complete
compliance with State Administrative Codes. There are other areas that it is not
possible to inspect at this point of construction. Polk County assumes no liabil-
ity for system operation. However, if failure is noted, the county will make
every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DIS-
POSED OF THROUGH THIS SYSTEM111
PLUMBER ON JOBS -_ LICENSE
INSPECTOR- - - - - - - - 4 - - DATED
V_
REPORT Or IIISPECTIO. ; I-- EGIJI•DUAL SE-JAGE DISPOSAL, SYSTEM
Sanitary Pernit 1,,2.
r State Septic
..A.IE X22 y - /`
. - � -��� .�� � T01•IIJSHIP
S t. Cro k- County
SRPTIC TA' ?R '
Size gallons. *umber of Compartments
• Distance From: Well �� ft, 12% or greater slope ft
'L Building ` ` ft, Wetlands f.
Highw3ter --ft.
iD�SPOSAL SYSTE:1 Tile Field or Seepage Pit (s)
Distance From: t1eli = ft, 12 % greater slope* ft
Building �! ft. Wetlands f-:
FIELD IZ� HiFhwater ft
Total lengkl of lines ft. Humber of lines - Length of
each line ft. Distance between lines ft. Width of the
trench ft. Total absorption area ( ff0 sq. ft. Depth
of rock below tile in. Dp-pth of rock over tile . in.. Cover
over.rock,, Depth of tile below grade in. Slope of
trench in per 100 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS .
?Dumber of pits si diameter t. Depth below inlet
oun p't: _ no. .Total absorption area
sq. ft.
.S uare feet of seepage trench bottom area required
Square feet of seepage ; ar a equired
Inspected ti Title*:. .
Approved Date 197
Rejected Date 197
EH 115 L C � �� g
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
f�
P.O. BOX 309 �" I S�, nr
MADISON, WISCONSIN 53701
REPORT ON SOIL BOR111�'GS AND PERCOLATION TEST
LOCATION: h '/a, '/4, Section 1A, TQ N, R Oz-ior) W, fiowrtshi}9-or Municipality —5 w
Lot No. , Block No County
� � Subdivi ion Nam
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET ��/ SOIL TYPE
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER OF SOIL
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P
d
P;0 36' l 1 /00
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B— r —7
7,, "
7 r . �� � � �� it A�l� • cJ O 'J,
za
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of s u 9ble areas. Indicate number of square feet of absorption area
needed for building type and occupancy. 6 / / 3� p ova. / Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
Hlb
1 )�a
VT Ir
L A I\
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t1
I; the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my knowledge and belief.
Name (print) - r f i c a t ip n No.
Address
Name of installer if known
CST Signature
COPY A —LOCAL AUTHORITY
State and County State Permit
PLB67 Permit Application County Permit
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
Sc.
B. LOCATION: PL 0 Section T_t;_V N, R k_-�or) W Lot# City _
Subdivision Name, nearest road, lake or landmark Blk# Village
Townships
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family '' Duplex No. of Bedrooms \ No. of Persons _x
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES 4 -1q0_ # of Bathrooms
Automatic Washer L , - - 'V - ES — NO Other (specify)
E. SEPTIC TANK CAPACITY Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation — Addition Replacement_ Prefab Concrete L�
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) , .�_3) Total Absorb Area / / sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length, ' Width 1 2 e Depth " Tile Depth � '! No. of Lines Z
i�
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Cert' ' d Soil Tester, c p
NAME 6eF / C.S.T. # Z c- 5/'G and other information
obtained from i v ow uilder). _
Plumber's Signature MP /MPRSW# Phone # `/� - ✓ y
Plumber's Address
V
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
A- led
tv
y
\� L7
Do Not Write in Space Below FOR DEPARTMENT USE ONLY _
Date of Application _ Fees Paid:_ State /0,0c
County -�' . li Date �ZJ Z
Permit Issued /Reje ed (date) //, Agent Name
Inspection Yes7No Valid# Date Recd
1. county (white copy) 3, owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/11/76