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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS `/i2 .471ZEy ��NE
SUBDIVISION / CSM# GG6 �� Del / LOT
C/i�3
SECTION 2 _T0?1?_N-RAW, Town of
(,.)Es
buj
ot
oT
ST. CROIX COUNTY, WISCONSIN
54 )P" I I'
A 7
6, 1
PLAN VIEW
EVERYTHING WITHIN 100 FEET OF SYSTEM
By zot 'is3
1 JFNTS Alorr; /I14rA cz.*srreS ow,v i It r/G jL-cNT .La7S,
I I
i
lif/u��SE �/b5n/iQr'i� ,QfE4 �EE4s'T �_
1 ' A!U/0 ;A4,G1Cq. r - - Eltlsr'A
S/I I 21WJ jf
1
I
.NE
I
� g0• — 1 Er i STu�Jc,
♦� ,' `�, I Peon
I
� �qAiNci�ca �� 1
;ut ,� � I
BENcN.IU1iK- TOP 4w -<rAvc i-,owr
No<f !o'14 E410-/00:0
E
/sy •r S«,Td
A&may •4,,AW
.2/0' To %.40
KR,+7tzft, AAAJE
SAG• c T.A,K frIstiNL
ARROW
Provide setback and elevation inform on reverse of tFiis form.
Provide 2 dimensions to center of septic tank manhole cover.
,4o7-
f
S�2
BENCHMARK: zo� o f SE / / /C 7fiy. MA A/u F 16V E 4- �o
0 oc�
ALTERNATE BM•
SST/NL SEPTIC TANK / / N
Manufacturer: �iEgE,p Liquid Capacity: : /.fop
Setback from: Well Sri'' House 1,;2 • Other
Pump: Manufacturer Model# Size
Float seperation — Gallons/cycle
Alarm Location
IPEPcA<<�/�T SOIL ABSORPTION SYSTEM
Width: S Length 51" Number of trenches S
Distance & Direction to nearest prop. line: LJEsr G '
Setback from: well: /06 ' House 73 , Other foo, Fjo-
Building Sewer
ST outlet . 30,
PC inlet — PC bottom Pump Off
ELEVATIONS
ST Inlet
Header/Manifold %Y- 07' Bottom of system %S,</O'
Existing Grade l oo.yo' Final grade Z _9a'
DATE OF INSTALLATION: 9
PLUMBER ON JOB:
LICENSE NUMBER: �'i�i%S 33SS
INSPECTOR:
3/93:jt
I
Wisconsin Department of Industry,
Labor and Human Relations
Safety.and Buildings Division
GENERAL INFORMATION
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
Lounty:
ST. CROIX
Sanitary Permit No
Permit Holder's N me: ❑ city Village Town of:
MCALLISTIR, JEROME
CST BM Elev.: Insp BM Elev.: BM Description.
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Do
G
Aeration
o ding
TANK SETBACK INFORMATION
P / L
WELL
BLDG.
Air I to
Vent take
ROAD
�/�
a
NA
5Aeration
NA
PUMP / SIPHON INFORMATION
Ma Demand
Model Number GPM
TDH Lift FjjctTon TDH Ft
Forcemai Length Did. Dist. To Well
Cnil ARCnRDTInN CVCTFM
Ci rVATInN neTe
ax
mho
STATION
BS
HI
FS
ELEV.
Benchmark
7 7a,
Bldg. Sewer
C
Stif)IiIi Inlet
I
St/Of Outlet
Dt Inlet
Dt Bottom
Header FMa -
13,!'
j
Dist. Pipe
3 53
r
Bot. System
Final Grade 0
BED / TRENCH
Width I
Length r
No. Of Trenches
PIT
No. Of Pits
Inside Dia
Liquid Depth
DIMENSIONSvDIMENSIONS
SYSTEM TO
P/L
BLDG
I WELL
I LAKE/STREAM
LEAC
Manu acturer:
SETBACK
CHAMBER
e
INFORMATION
Type <
0
A
OR UNIT
System: (�„�
r11C712101 ITInki CVCTGAA
Header „
Distribution Pipe(s)
x Hole Size
x Hoe Spacing
Vent To Air Intake
Length _ Dia
Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Syste_Mi,�
Depth Over -, !/
Depth Over i -
xx Depth Of
I
xx Seeded / dded
xx Mulched
Bed /Tranrh CanteF y� — L�r
Bed /Trench EdgW-
Topsoil
❑ Y ❑ No
❑ Yes ❑ No
1
'
i
J
COMMENTS: (Include code discrepancies, persons present, etc.) #LXiS �,X? cCAr1/-"
LOCATION: Hudson.7.29.19W, NNW, SE, Lot 33,,Krattley Lane
J
_ O�lan r vision required? ❑Yes E3,No / O
Use other side for additional information. /
inspector 'sSignature Cert No
Date
-dCJ4r-
ADDITIONAL COMMENTS AND SKETCH
p SANITARY PERMIT NUMBER:
�i"
MMO�
�— CA\IITADV DCDA/IT ADDI 1t%A1r1nL1
a ol��� W1 vvw a P1.. . . r§aEwa@ . I r . r.VI'a . 8Yvv
s In accord with ILHR 83.05, Wis. Adm. Code
C
os
STATE SANITARY PERhqT q
—Attach complete plans (to the county copy only) for the system, on paper not less than
ai$g3
❑
8'% x 11 inches in size.
Check if revision to p evious application
—.See reverse Side for instructions for completing this application.
STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER
PROPERTY LOCATION
r
�J�/a '/4, S T` , N, R E (Or
PROPERTY OWNER'S MAILING ADDRESS
LOT Ill
BLOCK K
ATE
21P CODE PHONE NUMBER
SUBDIVISION NAME OR CSM NUMBER
t/
n
N. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
State Owned O VILLAGE
❑ Public ®1 2 Fam. Dwelling— # bedrooms A Nu ✓v �
or of —
III. BUILDING USE: (If building type is public, check all that apply)
r, o
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. ❑ New 2. X Replacement 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 ## — Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ® Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
D U U , "_o a %Y. /U Feet YO Feet
VII. TANK
INFORMATION
CAPACITY
in allons
Total
Gallons
#of
Tanks
Manufacturer's Name
Prefab.
Concrete
Site
Con-
Steel
Fiber-
glass
Plastic
Exper.
App
New
isti
Tanks
Tanks
structed
Septic Tank or Holdin Tank
i
Lift PumpTank/Siphon Chamber
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print):
Plumber's Sig ture: (No Stamps)
-MiRMPRSW No.:
Business Phone Number:
�-r O
Plumber's Address (Street, City, State, Zip Code):
n
IX. COUNTY/DEPARTMENT USE ONLY
VAppro7vedD
Disapproved
Owner Given Initial
Sanitary Permit Fee pncluda Groundwater
�SurchargeFee)
�J
a
1
Wul 9t tamps)
t-
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 the 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 IicensAd
pumper whenever necessary, usually every 2 to 3 years.
6. 11 you have questions concerning your onstte sewage system, contact your focal code atlministrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
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. Cheek 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 in 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 in #1-7.
VII. Tank information. Fill in the capacity of every new and/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 holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
Vill. 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'fs 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, ground-
water contamination investigations and establishment of standards. `
i
SBD-63M (R.11/BB)
Aor 4
.o< I
4or
9.1
ljEw
N( E6
*71
Alvm: A466oper,00i AfAA To 4,f Cpt-r a//NJJo
` gliMq��', I
Pob�
YnnoN APkA FE tI C
,
-. BENtNMA - T P of :SfPr,c Ti}NK
M.4/lot£f�vER ;E<Ev. /vo.00'
5E on
Sq'i
G+ciS"r�NG
�ESi4EN<E
Al"r£: 4OTS 3.2-93- 3ti/
Aec <k �1EQ ey/%%,�ttiSTrlS
Ex, Sn"vG
G..,Lct
FRESH AIR INLET AND OBSERVATION PIPE
MAXIMUM 12'
ABOVE FINAL GRADE
MAXIMUM OF 42' ABOVE
PIPE TO FINAL GRADE
MARSH HAY OR SYNTHETIC COVERING I I
MINIMUM 2' AGGREGATE
OVER PIPE
DISTRIBUTION PIPE
I =
ELEVATION BED 6' AGGREGATE
BOTTOM PER SOIL, BENEATH PIPE
TEST IS
- 3 •S/o' FT.
144 APPROVED VENT CAP
4' CAST IRON VENT PIPE
SIGNED:
19l41W-
PLOT do CROSS SECTION PLANS
ZAPPA BROS. EXCAVATING INC
PLUMBING UNIT
Sf'f rA'*-1
4or 32
fi4sr .(or
N
VIA E
+NO
s SCALE
LICENSE:
It IA
s
DATE: 12
/
A;
TEE
SOIL T STING BY: 1
{it��ES' � Joifiy Sa.c.
•
PERFORATED PIPE BELOW
• COUPLING TERMINATING
AT BOTTOM OFSYSTEM
Wisconsin Department oflndusby, SOIL AND SITE EVALUATION REPORT Page lot 3
labor andJ-luman Relations
urvrsron oraawq a ouiaryo In accorct wlm n-nn oa.ua, rna. nun,. wuv
COUNT/ �s
Attach complete site plan on paper not less than 8 1/2x 11 inches in size. Plan must include, but
PARCEL I.D. >s
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
REVIEWED BY DATE
APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION
PR PERTY OWNER: /�
Mc ALL, S?�
PROPERTY LOCATION Q
GOVT. LOT N W 1/4 sC 1/4,S 7 T Z� N,R E (or) W
� 1vt
PR ERTY OW ER':S MAILING ADDRESS
t,QT BLOCK $ SUED.XME OR CSM h
t4414Le firDG�
—
1Z �./4ru)'
CIIS� STATE ZIP COD PHONE NUMBER
SA ��
EST ROAD
[]CITY ❑1rIL GE� OWN Nlf CA-VTL� JAr4 c
Nc/�sa� � )
( ] New Construction Use pQ Residential / Number of bedrooms (] Addition to existing building
P( Replacement [ ] Public or commercial describe
Recommended design loading rate bed, gpdd/9-0.6 trench, gpolft2
Code derived daily Dow gpd
bed, 112 trench, 1112 Maximum design loading rate O , S bad, gpd/D2 v ._ trench, gpd1(t2
Absorption area required
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations
It
Parent material Flood plain elevation, it applicable
$ =Suitable for system
c ENTIONAL
i 5❑ U
ND
S❑U
IN ROUND PRESSURE
WS ❑ U
AT•GRADE
8JS❑ U
SYSTEM IN FILL
fF9 S❑ U
HOLDINGTe
❑ S
U= Unsuitable for s stem
Ground
elev.
r&L�4L
Depth to
limiting
> factor
Z5
Ground
elev.
10O S4 It
Depth to
limiting
factor
.... ..�nnsrnrrn� vcvnvr
Horizon
De th
P
in.
Dominant Color
Munsell
Mottles
Du. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Y
Roots
GPD/ft
Bed iench
/�
IS
p.
_
L
1 r
rn
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s 2$
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"a#-IZ01qS ARK /nc.ArdA TN�U4NWr
AMim
MW
Man
Remarks: - HORI2o"JT ARW COc.Fv ICw �NCW�+•. r.. i
Name: —Please Print Phone: 7c% O Q
DST aevc� Mtv
� J oC]11
ress: W I
Date: 2y /g QCST Number: AIZ+
Spnature: a 7�
PROPERTYOWNERIL#k +LLIST&Q SOIL DESCRIPTION REPORT Page of
-PARCEL I.D.
2
Ground
elev.
j �•ld4
Depth to
limiting
flavc
> 12.75
Ground
VA
M
No no
Remarks: 4p2,l2A►3S ARC LOCA f& T4kOC4AWT 191 �100_M?J
MA
M.
Remarks: & 14a2.I20 rJ S A izo� LOc-o -r m -rm koUG N OUT
Remarks:
SBD-8330(R.0542)
VI'..
i
tit►`
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER �—, e I l u� t✓ L M L A 1.1i Jc4
MAILING ADDRESS `E Kru E e j La rye. E� XA � � o n 5 4-o
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 11 t'n.C4 s L 1&'
PROPERTY LOCATION �/i/u 1/4, C 1/4, Section Q_, T o1C) N-RCLW
TOWN OF H,n y5t\ , ST. CROIX COUNTY, WI
SUBDIVISION EA!` It- R i ti LOT NUMBER 3
CERTIFIED SURVEY MAP , VOLUME _, PAGE , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: c lam. 4-
DATE: �I 1 CT
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11/93
8 T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
-------------------------------------------------------------------
Ownerof property 11j«-06"'< VA 4- HU 1 e- LLocationof property�j,,,/l/4 5 r- 1/4, Section Of] jT_2_LN-R I cLW
Township_ Atio.-, Mailingaddress `H-� Krck+f(,'
Address of site 5 A rr\c-�
Subdivision name VIA c {` I d � C' Lot no. 3 '3
Other homes on property? Yes No
Previous owner of property J o 1, n I
Total size of property ,5� AcrrC'
Total size of parcel 307 i9�ncr
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes '-, No
Volume �8tL" and Page Number llq as recorded with the Register
of- Deeds
---- �-------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. 4 3SS 1?i , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Sign ture of Applicant
Date of Signature
Arp—pli ant
_ 7-7-y
Date of Si nature
• S 81 N LAND SURVEYING •
HUDSON , WISCONSIN 54016
(715) 386-2007
Nome First Federal of LaCrosse
Address 210 South Second Street
Hudson, WI 54016
oescription Lot 32 and 33, Eagle Ridge in the Town of Hudson, St. Croix County,
Wisconsin.
(Jerome W. and Hope L. McAllister)
N
W E
S
PLAT . DRAWING
This is not a complete Land Survey
N 890261E
200.99, 290.00'
1
Lot 33 Lot 32
�W'X121
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rea ^,
Co s
_ House c c
N � 1
2m M
= 24.51 c o
O z j°° Garage
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The location of improvements on this drawing are approximate•and.are based
on a visual inspection of the premises. The lot dimensions are taken from
recorded plats and deeds of county records. This drawing is for informational
purposes only and should NOT be used as a complete Land Survey
First Federal of LaCrosse has agreed to waive the minimum standards of AE-5
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Parcel #: 020-1124-60-000 0511a2005 10:04AM
PAGE 1 OF 1
Alt. Parcel M 07.29.19.562 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address:
Owner(s): • = Current Owner
LEE C & MARY JO NEUSCHWANDER
' NEUSCHWANDER, LEE C & MARY JO
412 KRATTLEY LA
HUDSON WI 54016
Districts: SC = School SP = Special
Property Address(es): • = Primary
Type Dist # Description
' 412 KRATTLEY LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.590
Plat: 1925-EAGLE RIDGE
SEC 07 T29N R19W EAGLE RIDGE LOT 33
Block/Condo Bldg: LOT 33
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-29N-19W
Notes:
Parcel History:
Date Doc # Vol/Page Type
07/23/1997 2000/398 WD
07/23/1997 814/119
2005 SUMMARY Bill #:
Fair Market Value: Assessed with:
0
Valuations:
Last Changed: 10/26/2001
Description Class
Acres
Land
Improve
Total State Reason
RESIDENTIAL G1
1.590
34,700
204.400
239,100 NO
Totals for 2005:
General Property
1.590
34,700
204,400
239,100
Woodland
0.000
0
0
Totals for 2004:
General Property
1.590
34,700
204,400
239,100
Woodland
0.000
0
0
Lottery Credit: Claim Count: 1
Certification Date:
Batch #: 111
Specials:
User Special Code
Category
Amount
Total Special Assessments Special Chargaas Delinquent Chargas
0.00 0 0
RRPORT OF IIISPECTIO?I--I'sIDIJIDUAL SE6IAGE DISPOSAL SYSTEt•1
Sanitary Permit
State Septic, -
At
TOWNSHIP
fit: roix ounty
SEPTIC TA7TK
Size O�V_ gallons. `:umber of Compartments ,
Distance From: T-jell �—
ft. 12% or greater slope ft
Building _ft. Wetlands
t �-- f
t �\ Highwater
ft.
DISPOSAL SYSTmi _Tile Field or Seepage Pit(s)
Distance From: well ft. 12% or greater slope eft
Building 9 ft. Wetlands -
fr.
FIELD Highwater ft.
Total length of lines41�
ft.
Number of lines_
Length of
each line ft. Distance between lines ft. Width of the
trench ft. Total absorption area 8 8 sq. ft. Depth
of rock below tile 1_Z4n. Depth of rock over the <-
in. Cover
Over roc:/in
- {i Depth of tile below grade �-in. Slope of
trench ,er 100 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS.
Number of nits is ame'ter ft. Depth below inlet
_,ft. Gravel aro _yes no. :Total absorption area
q. - ft.
Square feet of seepage t ch bottom area required _
Square feet of s age area required •'
Inspected by: r_•
f' Title:
Approved ( Date I 197.rl
Rejected Date 197
r �
oa
PLB67
State and County
Permit Application
for Private Domestic Sewage Systems
'DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required
A. OWNER OF PROPERTY
B. LOCATION:
Subdivision Name,
State Plan I.D. #
State Permit*
County Permit
s1#
County s .
Mailing Address:
A/W 3�- / .4
`/4, Section ., T&jjN, R/ 97 (or)
nearest road, lake or landmark Blk#
TYPE OF OCCUPANCY: "Commercial "Industrial "Other (specify)
Single family OK Duplex No. of Bedrooms_ No. of Persons-
City
Village
Township !s S10A1
D. TYPE OF APPLIANCES: Dishwasher -,& YES NO Food Waste Grinder X YES —NO # of
Automatic Washer _,K_YES NO Other (specify)
E. SEPTIC TANK CAPACITY^/p 06 Total gallons No. of tanks
'Holding tank capacity Total gallons No. of tanks
New Installation x Addition Replacement Prefab Concrete x
'Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1).r2)_y_3)_f 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 Depth Tile Depth 3� ^ No. of Lines j_
Seepage Pit: Inside diameter Liquid Depth Tile Size P"i
Percent slope of land Ci- jF*jr,;Z -,i Distance from critical slope O�
1, 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 ified Soil ter/o
NAME Y C.- r Cv eow CST # So,r/(r" and other information
obtained from t �1. _ pp\
Plumber's Signature MP/ PRSW# Phone #3 �� 20J�
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
i H62.20, including well).
411111b
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/%rA.�Sk fi •%�
Sty Pe..
L 40 Rss•`t��
P 23'xt/• 6ar►*6
P##1 eted
9E'
Do Not Write in Space Bello ; FOR DEPARTMENT USE ONLY
Date of Application % Fees Paid: State ID°D County � Dqto
Permit lssued/Re*ated ( ) Issuing Agent Name &)O
Inspection Yes_ZNo Valid# Date Rec'd
1. oounty (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 fill /76
• w
x
w
Yke
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 TEST /
LOCATION: �Y., S&'/a, Section ?, T21N, R (r)aownship or Municipality ,zurr�-'��
Lot No., Block No. County j`S , �'r�±,•�(
u ivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence �_ No. of Bedrooms 7 Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE:
.�SOiIL BORINGS lol- 3 `-7 -? PERCOLATION TESTS 2_ —
SOIL MAP SHEET AFg-S SOIL TYPE off ;7,0�� &f Gc - C;,`".-%;d i 1 S
PERCOLATION TESTS
TEST
NUM-
DEPTH
INCHES
CHARACTER OF SOIL
THICKNESS IN INCHES
HOURS
SINCE HOLE
WATER IN
HOLE AFTER
TEST TIME
INTERVAL
DROP IN WATER LEVEL, INCHES
RATE
PERIOD 1
PERIOD 2
PERIOD 3
BER
1ST WETTED
SWELLING
IN MINUTES
MIN/IN
P-
i3r
Sea
f,
Zo
2
2
Z
s
P-
'r
'
/Z-
21v
�f
Cr
Z
b
C
O�%'er
r%/
_/
2X_
1/z
/
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_ l
E"
00
7 I,
211 " ,0 )s„S
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s
of
if
6
e-
7 fr
.71 • rS_ Aleo-1,•� S
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
y
N
i, uie unuersigneu, nereoy certlTy mat the sou 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) s K`s 77D AP Certification No.�-S'� r9 9
Name of installer if known
CST Signature
=OPY A —LOCAL AUTHORITY
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