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• AS BUILT SANITARY SYSTEM REPORT
:ER . r K , TOWNSHIP SEC. AF TaN, R ^ Z L:W
ADDRESS �p , ST. CROIX COUNTY, WISCONSIN.
( ';DIVISION / LOT_,yj_LOT SIZE '
PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOD,' EVERYTHING WITHIN 100 FEET
Weli
I ,
i
-
,.
I I I
- -. ; - -- -- - -a— - - - -- L- J
In i
S CALL . !ID i A
'TIC TANK (S) I�?Le _ GR._ CONCRETE_ STEEL
N0. rings on cover _ Depth DRY WELL
:iCHES NO. of - width length area
no. of line width length area '
depth to top o€ pipe
, 11EGATE
4: RATE qs / AREA REQUIRED 7,90 d` AREA AS BUILT
riaimer: The inspection of this system by St. Croix County does not imply complete
nliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
.-em operation. However, if failure is noted the County will make ever effort to
, ?rmine cause of failure.
,ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST
`'INSP OR
DATED '7t PLUMBER ON JOB
LICENSE NUMBER 33 �Rr
State and County State Permit
PLB Permit Application County Per it #
i` for Private Domestic Sewage Systems Count
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
RJ r G'r l e " I I
, ,
B. LOCATION: S � /< $ j= /., Sec ion JA, T,21 N, R Y. (or) & Lot# -31-- City _
Subdivision Name, nearest road, lake or landmark Blk# Village
Towns /-_ ,T'e�n_
C. TYPE OF OCCUPANCY: Commercial Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher _< YES NO Food Waste Grinder _ YES X NO # of Bathrooms 2
Automatic Washer R YES NO Other (specify)
E. SEPTIC TANK CAPACITY AUM Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation a( Addition Replacement Prefab Concrete X
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) :S 3) � Total Absorb Area 0 q. ft.
New_ Addition Replacement *Fill System Flo
Seepage Trench: No. n . Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length ; Depth �' Tile Depth No. of Lines .�
Seepage Pit: Inside diameter Liquid Def r h Tile Size
Percent slope of land - /aw l, Distance from critical slope
I, the undersigned, do hereby certify that the information 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 Tes
NAME Denn I X ' f / O C.S.T. 45 !F L and other information
obtained from (owner/builder).
Plumber's Signatu MP /MPRSW# /76-6 Phone
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
(�- lie
e
I
I
s �
I
a
i
_ rt _ E
I
t._
)o Not Write in Space Below FOR DEPARTMENT USE QNLY O _
)ate of Application — _ f1 O Fees Paid: State Con 17 G Date ZY
Permit Issued /Rejected (date) /� Issuing Agent Name
nspection Yes No Valid# Date Recd
I. 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 6/1/76
Z
REPORT OF INSPECTION SEWAGE SYSTEM
• San.itaAy Petcm.i.t
' State SPp.t.ic G
NAME �� o G' rownahip S CAa.ix County
Location ,- , Section J
SEPTIC TANK
Size Z2&0 gaZton.6, Numbers o6 CompaAtmentd I
Distance FAOm: WeZZ Alo &J fit. 12% on gAeateA ztope',,�-/it
Building it. WetZand.6
H ighwateA it.
DISPOSAL SYSTEM
Distance Fnom: WetZ /(* A)W it. 12% on gneat zZope�04t-
BuiZding it. WetZand6 Ft.
N.ighwateA St.
FIELD DIMENSIONS:
wi dth oS tAench ix. Dept o no ck' below tiZe
5 Z Length of each Zine it. Depth o6 Aock oven Cite '0 i n.
NumbeA 06 Zine.6 3 Depth o6 tiZe below gnade .in.
To 2engh as 2.ined4. S2ape a6Aench in peA 100 i.
0
ID� Dist b etween 2 ine•6 __I t. Depth to b edxo ck
LA), 'Totat ab.6oxbtion aAea jt Depth to gnoundwateA
5
CO Requited area �,Q� it Type ob Covet: Papers % Stxaw
PIT DIMENSIONS: G
NumbeA of pits GAaveZ anound p.it.6 ye.6 no
Outside d.iameteA it Depth beZow .inZet it.
2
Ta aZ ab.6 b .ion aA A
AAea Ae ed it2
INSPECTED B TIT L
APPRU VE �� , DATE 197
REJECTED ,DATE 197_.
1�
f
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
LOCATION: - SG' /4, ' /<, Section /�, T�—LN, R�� IP(or) Township or Municipality
Lot No. _, Block No. ��'���� kd 6 e- — County ,
Subdivision Name
Owner's Name: ;►� �Y
Mailing Address: S/e Ze S1 /�/ / a O r0A,
TYPE OF OCCUPANCY: Residence X No. of Bedrooms J-' Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 5 - 29 PERCOLATION TESTS
1 / , S7- 3 - 7
SOIL MAP SHEET 7 SOIL TYPE Rx Po' vfztrl' ' t
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
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P qp _e e r e // l`4 /i /v d --3 712—
P Z I0 " .e e- ,t'�d /I/ 3
P_. Y�" _re 2 90 r t & A,# /y A/0
SOIL BORING TESTS
TEST TOTAL DEPTH --- DEPT44- 3_OGROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B_ o �rt 7 9(0'' 6 " 3$" l/, sa" S +Gw, L.
Sy" s Crr,
B- 3 16" ,� < 7 96., 6 "tf, 3,2 '' s�, S8" S+ G'K.
llt e, , 6,. 6 // �/ G
B_ / �" /1`eN� 7 y(p �. `!r �5. 5/� �' �Fj / o
PLAN VIEW (Locate..percolationtests,soiI bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of.square feet 9f absorption area
needed for type and occupancy. �_ �1P6b ` S Kr` /,a� /e Ares �rh- Sys�s1 Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope. •F-
o ef a
a�
_ rm st
40/
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Q
] �ft _ ctv� , D' d C �� r 0 SrB �r 7 ¢ - r 0 t e _ �` �e � r �o
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) Q r Certification No.
Address
Name of installer if known
��L 1
COPY A --- LOCAL AUTHORITY CST Signature