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ST. CROIX COUNTY ZONING DEPARTMENT
` AS BUILT SANITARY REPORT
Owner 0
Address 2 e `
City /State I� UDSokj (,) Jfc,
Legal Description:
Lot 3c Block Subdivision/CSM # p� P �S p f S ; �y f
%, I�)1 %, N W Sec. J � , T 7 W, Town of �Ao o PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK I
e v fix n N u INFORMATION.-
Tank manufacturer - Wt R Size ST/PC 1 00 o / Setback from: House a3 Well S O t P/L 8�)'
Pump manufacturer --- -Model
Alarm location -
(HOL
Setbacks: Service road Vent to fres Water Line
Meter location .............
Alarm location
SOIL ORPTION SYSTEM:
Type of system: -T&�1 R Width
�' Length � `� Number of Trenches
Setback from: House S 1' o�
Well o P2 6I
�� Vent to fresh air intake 13
ELEVATIONS
Description of benchmark ,, q o v o S, h .� y !C fi S "� �o n Cja Elevation
Description of alternate benchmark �—
Elevation
Building Sewer ST/HT Inlet ST Outlet a 4 9 PC Inlet —�
PC Bottom Header/Manifold U Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade
Date of installation _ ( 3 / ermit number State plan number
Plumber's signature r� °r ►s r License number a as U Date3 / /0 U
Inspector �o h i s � N R
compkte plot plan or
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
� - TkD tj s
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/ � louo yal fi��'1C
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INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit lvo.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ST. CR IX
Permit Holder's Name: ❑ City ❑ Village [Town of: State N AP 5
THEESE, RONALD HUDSON
CST BM Elev.:- Insp. BM Elev.: BM Descrpt Parcel Tax No.:
fD � s�v�
TANK INFORMATION FLFVJ14TI DA A A9900186
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Qt cc v k N Ousn ) Ben h r L• �r7Q / � U
Dosing
Aeration Bldg. Sewer
Holding t Inlet
TANK SETBACK INFORMATION ( Sytl i lt Outlet
TANKTO P/L WELL BLDG. Air to
i ntake ROAD Dt Inlet
ir
Septic A Dt Bottom
Dosing NA Header /Man.
Aeration NA Dist. Pipe p g'� 3 �
1 Holding Bot. System p /b
PUMP/ SIPHON INFORMATION Final Grade �• �'G:��
Manufacturer ge mand
Model Number GPM
TDH Lift Friction Sv$WM TDH Ft
Forcemain I L Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED / RE Width 3 Length No. Of renches PIT No. Of Pits In Dia. Li uid Depth
DIMEN I N 7J DIMENSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING /,��?
i
INFORMATION TYp CHAMBER o e u er:
Sys em 611 `f"/ 00 OR UNIT �Gr
DISTRIBUTION SYSTEM
Header /Mani I fr Distribution Pipe (�ji x Hole Size x Hole Spacing Vent To Air Intake
�/
Length Dia- Length / rt ✓� 7 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 Bed /Trench Edges Topsoil [I Yes 1:1 No ❑ Yes F] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON n 17.29.19 613,NE,NW 443 PARK LN — PARK VIEW EST LOT 32
i �
kpm t co U->1
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's SignalMre Cert
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Vi s co ns i n SANITARY PERMIT APPLICATION of E WashnlgonA 8 "Bi °°
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. /
• See reverse side for instructions for completing this application State Sanitary Permit Number
33F -i35'
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
fP Owner N Property Lo tion N,11/ E (or) W
�'1 /4 1 14, S T ,
Prop Art 0 wner'sM Address Lot Number Block Number NP, �7
City"t Zip Cod q Phone Number Subdivisiorl.Akirme or CS Number
(15 ) V.
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it N est Road
❑ village
Public 1 or 2 Family Dwelling - No. of bedrooms own OF � [rGZ
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) �� , 2"l 19 . ( l'�;
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. jkReplacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one) In.41*a WaY k. ter• 4 s4XeW00114A.1- 4* 31. 4
Non - Pressurized Distribution Pressurized Distribution Exrimental Other
11 ❑ Seepage Bed k 21 ❑ Mound 30 E] Specify Type 41 ❑ Holding Tank
12 ,Seepage Trench :L I )fiA4)9 22 ❑ In- Ground Pressure { _� 3 , x 7S � 42 C] Pit Privy
13 [] W' Seepage Pit /� �7- 43 [] Vault Privy
14 ❑ System -In -Fill 3 1JeAfteir. S{ I IP�I� k l N �t �Qr<i "rh t ►vc
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade
/ r� Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. 'rich) ti
G n
Q S O - 7 , 5 0 O 7 Q 0 Feet 1 v - Feet
Capacity v
VII. TANK in all0 5 Total # Of Prefab. Site J ber- Exper.
g
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- lass Pl astic A pp New Existin structed Tanks Tanks I o v a f Uw
IJo A) El El 1:1 13 Lift Pump Tank /Siphon Chamber El El ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's N rint) Plumber's Sign at re: (No Stamps MP /MPRSW No.: Business Phone Number:
^
1121 3 o
Plumber's Address (S reet, City, State, Zip Code): Nj
In In lt4 3 oU
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ant Signature (No Stamps)
[� ❑
pproved Owner Given initial / Surcharge Fee)
Adverse Determination �" / 1 � 26 i�.
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
8BD4398 (R t tom) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usual iv every 2 to 3 years.
66.. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin Safety and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
i. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
I if k received experimental product approval from
tanks for this experimental approval on tanks ece ed e o
holding to s o s s ste m. Check ex
P PP Y P P PP
9 Y
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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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 O N S residence located at:
Sec. T N, R_AI_W, Town of HkA0 St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condi ion and it appears to be functioning properly.
Last time serviced 9
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer ( if known) : UN U �;�
Age of Tank (if known) : u*1 Y-)j UV J
lAJ ( 3
J 1►h � akrh�.k,J� lL
(Sign ure) (Name) Please Print
(Title) (License Number)
'5
(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, Wis. Adm. Code (except for inspection opening over
outlet baffle).
Name �OirlQeg�Q� Signature
6
MP /MPRS as
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i
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
_ A.C.E. Soil &Site Evaluations
Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and
St. Croix
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. parcel I.D.#
r_ __-�- _. ,� 0 - 11.z9- -D0d
APPLICANT INFORMATION - P/ ►�i..;i►fd� '0n.
Personal information you provide maybe used fo n purposes (Pi) y,E s. 15.04 (1) (mp. R iewed By Date
y
Property Owner roperty Location
Ron & Ka Theese ` �'° Vt. Lot N 1 NW 1/4 S 17 T 29 N,R 19 W
Property Owner's Mailing Address " . t # Block # Subd. Name or CSM#
443 Park Lane 32 NA Park View Estates
City State 2 Code Rfj er t' City Village ❑Town Nearest Road
Hudson WI 4� �� - 180,^ Hudson Park Lane
El New Construction Use: ms 4 ❑Addition to existing building
❑ Replacement ❑ Public ca r ' cribs
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ftz _ 0 trench, gpd/ftz
Absorption area required 857 bed, ftz 750 trench, ftz Maximum design loading rate .7 bed, gpd/ftz .8 trench, gpdt tz
Recommended infiltration surface elevation(s) 90.0' ft (as referred to site plan benchmark)
Additional design / site considerations Install trenches using high capacity infiltrators.
Parent material Out wash s & gr. Flood plain elevation, if applicable NA ft
S= Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system ®S ❑ U ®S ❑ U ®S ❑ U ®S E:] U ®S ❑ U El S ® U
SOIL DESCRIPTION REPORT
#
Depth Dominant Color Mottles Structure GPD /ftz
Burin Horizon Texture Consisten Boundary Roots
9 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -4 10YR3/2 None sl I fcr mvfr cs 2f 0.4 0.5
2 4 -9 10YR4 /2 None is o sg ml gs if 0.7 0.8
Ground 3 9 -19 1 0YR5/4 N one Is o sg ml gs - 0.7 0.8
elev -
93.81' ft 4 19 -38 10YR6 /4 None is o sg ml gs . - 0.7 0.8
Depth to 5 38 -98 10YR6 /4 None strat. s o sg ml - - 0.7 0.8
limiting
factor
> 98" u y 7a
Remarks:
2 1 0 -4 10YR3 /2 None sl Ifcr mvfr cs 2f 0.4 0.5
2 4 -12 10YR4 /2 None is o sg ml gs if 0.7 0.8
Ground 3 12 -19 10YR5 /4 None is o sg ml gs - 0.7 0.8
elev
94.31' ft 4 19 -38 7.5YR6/4 None s o sg ml gs - 0.7 0.8
Depth to 5 38 - 98 10YR6 /4 None strat. s o sg ml - - 0.7 0.8
limiting
factor
>98 -
Remarks:
CST Name (Please Print) Signature: c Telephone No.
James K. Thompson 715- 248 -7767
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, WI 54020 4/21/99 3602 1003
I
PROPERry OWNER Ron & Kay Thews SOIL DESCRIPTION REPORT 1003 Page 2 of 3
PARCEL LU A.C.E. Soil & Site Evaluations
Depth Dominant Color Mottles Texture Structure nsistence Boundary Roots GP D11F
Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0 -4 10YR3 /2 None sl Ifcr mvfr cs 2f 0.4 0.5
2 4 -9 10YR4/2 None Is o sg ml gs if 0.7 0. 8
Ground
elev 3 9 -19 10YR5/4 None cs1 lmsbk mfr cs - 0.4 0.5
94.01' ft 4 19 -38 7.5YR6/4 None sl 2m mfr cs - 0.5 0.6
Depth to 5 38 -95 10YR6 /4 None strat. s o sg ml - - 0.7 0.8
limiting
factor
>95
Remarks:
1
Ground
elev
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
limiting -
factor
Remarks: -
Ground
elev
Depth to
limiting
factor
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State ��u�- SQ^'/�� Parcel Identification Number
LEGAL DESCRIPTION
Property Location *• '/,, '/4, Sec. , T�N -R,4;L_W, Town of
4 ,,eW y /f'yl! z - / , 7 S Subdivision ,Lot # �
Certified Survey Map # /�S , Volume , Page #
Warranty Deed # Xl 7S—_q Volume , Page #
Spec house ❑ yes,d no Lot lines identifiable /o/yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of 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 function 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 plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in 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
f the ee yea�iration .
o�'
�, d
_
SI(iNAtUkE 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 owner(s) of
r9perty a c�ed a , by virtue of a warranty deed recorded in Register of Deeds Office.
SI GG1 A 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. I STATE BAIT OF WISCONSIN FORM i—IM T"la ePA:: aesaCaVSO teas �aaov+e9eca paT+
alllT CLAIM D EED
t �I
4 10
el
NEC14ST I
� t� i
Leslie J. Theese ed and unr+rmarx'iad r;on ST. C PO CO, Wt& r
W. d. for Reoxd Mds 9th
! ................................ ...... - - -- .............. ........................... - -- .... d, Ap ril
1 Quit- elainis to ...... RQ141.d_• C.._... he a _aivorc.d._i f 11.40 A
ii A rr�narried_pErson ..................... -• - - -- ....... ... .... •----• -.............
'
f�
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. �.
------ - - - - -- ......................... .... ...................................... - ............._..._
�j the following described real estate in --..- .St.. -..0 &01.X ............. Coun
.. __�_-- � —� - -- - - - --- - - -:,
i
State of Wisconsin: II IM1 To
!i i
I
"fan Parcel No: .......... ................... l
Lot Thirty -two (32), Park View Estates First Addition to the Town
of Hudson.
This deed is executed pursuant to the finding and order entered on
the record by the St. Croix County Circuit Court, Branch I, at
divorce hearing held March 10, 1986,
t.
This .. -__15 - . -_. - -- homestead property.
(is) (is not)
Dated this ........_. .1.Oth- -- -- ...... day of ---- -- - - -- March - - - -- - - - -- - ...._.. ........... 19.8.x.. .
l / -
-- - - -- _ _ .... ..... .... _... _(SEAL) �_,... .'C .L�'. -. - / -` -.t C :�...._ .(SEAL)
• .Leslie J. Theese... _ - - -
- .(SEAL) ... - ....._._... -- ...(SEAL)
-- -•- • - - --
• _. -- ---------
AUTHENTiCATiON ACKNOWLEDGMENT
Signature(s) Leslie J. Theese STATE OF WISCONSIN
/1 -------
I ss.
au }meted is 0- 133Y of mars _____________ ._. y
h 1986 Personally came be -ore me this __- _- ____ day of
—
/r -- ------ •--- •--..._..- ------• --- - a .- _ -_-. ._._. 19 ---- the above nr.aled
•._L�.. R.....Re. nstz
---------- -- •-- --- ------------ -- -- -- -• -- - - - - -- -- - - - - - --
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, -- --- --- --- – - - --- -- - – -- -- -- -
authorized by § 706.06, Wis. Stats) to me known to he the person _.... . who executed the
foregoing instrument and acknowledge the same.
THIS INSTRU'M'ENT WAS DRAFTED BY
Reinstra, Van Dyk- &.Needham,-_S..C..-
New, Richmond WI 54017 __. Notary Pnhlic County, Wis.
(S;znature� may he authenticated or acknowlcdi.;ed. Both MY Gxnmission is permanent.kif not, state expiration
;iry not rt,re. cart'') date: - -.. -. - _ -- -......, 19. . --...)
•Ji•a - C Ders..,n± 9;r in • .•a; a: Ay .h• id he A- wt 1 �!
�._ IT \1'F 11 k1' M K Iii O`::1 \' S�.-)^ =k N o. 13003
M.y Yiile•«a*R "rjl`.'ij FOPNI .\..,. 'I
AS BUILT SANITARY SYSTEM REPORT
*7 A l TOWNSHIP S EC .L7 N R 7 T I , j1 y�
R _ t � r .� J..1 _
OWNE .� � , L.
P.O. ADDRESS Lj k of s �.� (,�, i , ST. CROIX COUNTY, WISCONSIN
SUBDIVISION ' , , 11A , , LOT LOT SIZE � ✓ `� � '�' +�
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100FEET OF SYSTEM
41 Al
14° `
. k ,
MV
SEPTIC MFGR. w r s for CONCRETE c / STEEL
NO.oT rings on cover Dept DRY WELL
TRENCHES No. of width a gt area _
BED no . of lines wi tai — 9 lengt - 3 5` area
i
depth to top of pipe
AGGREGATE
PERK RATE �` AREA REQUIRED C AREA AS BUILT
DISCLAIMER: The inspection of this system by St, Croix 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. St. Croix
County assumes no liability for system operation. However, if failure is
noted the County will make every effort to deter 'ine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUG THIS SYSTEM.
INSPECTOR,,
DATED 11' / — PLUMBER ON JOB 46
LICENSE
L
i
PURPORT OF ITISPECTIO'_1-- Ii4DIVIDUAL SEWAGE DISPOSAL SYSTEM
Snnita_ry Permit x
• • r . State Septic
0
TT•IIISHI P
�St. - Cr - oi County
SEPTIC TAM".
Size /� `t gallons.
-umber of Compartments
Distance From: Well _ IjC' ft. 12% or greater slope f1.
r Building 2�! ft. Wetlands
liighwater - ft.
DISPOSAL SYSTF:4 Tile Field or Seepage Pit(s)
Distance From: Well ft. 12 % greater slope ft
Building J ft. Wetlands f.
FIELD Righwater ft.
Total length of lines :% ft. !lumber o-. lines Length of
each line ft. Distance between lines
- �.-- -- �,- ft. Width of the
a .. � trench / ft. Total Depth absorption area / s . ft.
P .G.r q
f rock below= tile /'
,. `in. Depth of rock over tile c in. Cover
ck4 Depth of tile below grade - in. Slope of
trench in per ft. Depth to Bedrock - ft. Depth to
,round water
PITS
=lumber of - pits Outside diameter ft. Depth below inlet
ft. Gravel around pit: yes no. Total absorption area
s q. f t .
.Square feet of Isee e trench bottom area required :.quare feet of it ate'' r quired Inspected byTitle*: • _
Approved _ Date 197
Rejected Date 197.E
EH 115
. , WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS p
LOCATION: , At' /a, Section , T�N, RR_ III (or) W, Township or Municipality
Lot No. ock No. �q f �/ — County �� �/'�' l r
/ Su ivision Name
Owner's Name: ✓ e /�L e-
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms — Other
EFFLUENT DISPOSAL SYSTEM: NEW t- ---- ADDITION �/ REPLACEMENT
DATES OBSERVATIONS M�ADE::� SOIL BORINGS -3 — ;Z " 2 v PERCOLATION TESTS � � 2
SOIL MAP SHEET R -? SOIL TYPE `Z �� 04"41-1
_ PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
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 -2
J 3,6
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/
B 3 - -_ T
B fl I
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. dicate nu er of square feet of a R= n area
needed for building type and occupancy. �� e scale
or distances. Give horizontal and vertical reference points. Indicate slope.
t N
rd
C
ARI I
ON!
t
i
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) W A l l Certification No.
Address
Name of installer if known
CST Signature��
COPY A —LOCAL AUTHORITY
State and County State Permit #
PLB67 Permit Application County Per
for Private Domestic Sewage Systems County
• f
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
S M ILL R Box j- 87—
B. LOCATION: IV b� % %, Section [_7_, T� N, R� E (or) W Lot# City
Subdivision Nam, nearest road, lake or landmark Blk# Village
�
Township 1'4 U P S 6 k'
_ A- R � r � �J �' �`t"� S
C. TYPE OF OCCUPANCY: *Commerce e *Industrial *Other (specify) *Variance
Single family V Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder Z'' YES # of Bathrooms
Automatic Washer V YES NO Other (specify)
E. SEPTIC TANK CAPACITY () 0 Total gallons No. of tanks
� D
*Holding tank capa ity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete L/
*Poured in Place Steel Other (specify)
F. EFFLUE T DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) _ Total Absorb Area sq. ft.
New Addition Replacement *Fill System (r Z
Seep ge Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length Width Depth Tile Depth 0 No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land 3 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 Certified Soil Tester,
NAME 2 le- h X p W 1 D P <I IQ S C.S.T. # 13 ( and other information
obtained from (owner /builder). _ 2 Z
Plumber's Sig nature :_ .� MP /MPRSW# A1� 5 3 Phone l z 3 !
Plumber'! ze
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
L o T 3 PoLtk (1.4-4,�-
14 0 ME
1=P
S-
I t' ll
Do Not Write in Space elow F R DEPARTMENT USE ONLY
Date of Application Fees Paid: State 61-D Co nt Date
Permit Issued /�d (ate) Issuing Agent Name
No Valid# Date Reed
Inspection Yes
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)
l Revised Date 6/1/76