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Parcel 020-1022-60-000 05/24/2005 11:54 AM
PAGE 1OF1
Alt. Parcel M 14.29.19.103E 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
* WENTE, ARLEN L & KATHERINE A
ARLEN L & KATHERINE A WENTE
779 HOLDEN LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 779 HOLDEN LA
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 5.020 Plat: N/A-NOT AVAILABLE
SEC 14 T29N R19W PRT NE SE COM E 1/4 Block/Condo Bldg:
COR; S 0 DEG E 1162.88 FT; S 68 DEG W
455.51 FT; S 88 DEG W 414.35 FT TO POB; Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
S 88 DEG W 347 FT; N 1 DEG W 630.92 FT; 14-29N-19W
ELY 347 FT; SLY 630.28' POB LOT 5
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 708/525
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.020 58,100 110,600 168,700 NO
I
Totals for 2005:
General Property 5.020 58,100 110,600 168,700
Woodland 0.000 0 0
Totals for 2004:
General Property 5.020 58,100 110,600 168,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 218
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
6
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 11 r /-P. n LO 2, q\ 4 -a-,
ADDRES _1_3 9 4al ( v, j.cj~G_
5410 1 ~0
SUBDIVISION CSM# LOT
SECTION, ! T261) N-R / W, Town of 1~(,A- d sr D yl
1~5E
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1 .
now
0
fa
6 fiat ,
i
Z6 ~
~p ao 7 5d() 4o L
o INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: , ) f7~ lv~
ALTERNATE BM:
SEPTIC TANK PUMP CHAMBER / HOLDING.TANK INFORMATION
Manufacturer: Wa ►~S 2 r ~r ~ Liquid Capacity: f daa
Setback from: Well House / Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
r1
Width: 2 Length Number of trenches A al7°t_
Distance & Direction to nearest prop. line:
Setback from: well: _HouseOther
ELEVATIONS
Building Seder ST Inlet: ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: y` 7-3
PLUMBER ON JOB: PZ~0-On A&j.I-Y Ur.
LICENSE NUMBER: -?3 /
INSPECTOR:
3/93:jt
L~~i
Labor and Human Relations RelaLtions ions t 4.29.19.1RIVA- Sf&AGE SY?TEMane County:
'
Safety and Buildings Division INSPECTION REPORT
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 193464
Permit Holder's Name: ❑ City ❑ Village [Town o : State Plan ID No.:
ENTE ARLEN L & KATHERINE A HUDSON
CST BM Elev.: / Insp. BM Elev.: BM Description: Parcel Tax No.:
A06 020-1022-60-000
Q-s
. GD
TANK INFORMATION ELEVATION DATA A9300122 (>`fe?fl `j
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic O.1t"e7c5 cgh,C 0441
Dosin
Aeration Bldg. Sewer
Holding St/V# Inlet
TANK SETBACK INFORMATION St/ 0 Outlet V5 970!5
Vent
irIto ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
Septic .x.('06 B/ NA Dt Bottom
Dosing NA Header /Ma+a.
/
Aeration NA Dist. Pipe 17'
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade S,Qp 74.--
Manufac Demand t`A°"c .7~ 0
Model Number GPM
TDH Lift Fri
oss ction Syste Head TDH Ft
Forcemain Length Dia. Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~ ~ DIME N
SETBACK G Manufacturer:
LEAC
SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION TypeO ORUNBT o e Num eTr-CHAME
System:
DISTRIBUTION SYSTEM
Header /M&ffl+0itf_ zt Distribution Pipe(s) , x Hole Size x Hole Spacing Vent To Air Intake
i
Length Dia. Length 51 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 /;4@4;4h Center 39 Bed/ Ueweh Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION:HUD/SON 14.29.19.103E ne se Holden lane
/
Plan revision required? ❑ Yes p'Iqo-
Use other side for additional information. Aatwes~~,
-6710 (R 05191) Date Inspector's Signatur Cert. No.
SBD
[ r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
171 DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
J ,C
_.a.,.,.,.s....,~„_.~
STATE llf3revisl ITARY ERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than
8/z ' x 11 inchesin size. ❑ 3n previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPS TYOr ER PROPERTY LOCATION
'/4s '/4,S L T29,N,R E or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
-7 2 -9 Yo n L a, Y) ~el
CITY, 7ss TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
o~, LO; 1<1-601~ W6478
V
ESJT RpAD &'n
II. TYPE OF BUILDING: (Check one) 11 State Owned VILLLAGE : ,.J OA NE
/ ten ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms A L TAX NUMBEK(b)
III. BUILDING USE: (If building type is public, check all that apply) dj p2 0 ^ l O oZ ^ CO
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) 1.0 New 2. 9 Replacement 3. ❑ Replacement of 4.0 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 (4( 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 12. 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) ELEVATI N
1-0 V _r -77 1_7 Feet Feet
4ey VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank d CesC/^L4X_K~~ ^
LI [I i El 1 11 1 Ej I El
ift Pump Tank/Si hon Chamber
VIII. 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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
1.331 1 S -7V
PI tier's Address (Street City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY/
Groundwater a e Issued gog Agent Signature (No Stamps)
_j Disapproved Sanitary Permit Fee (Includes Surcharge Fee)
Approved ❑ Owner Given initial 9 n y J3
Adverse Det rmination v
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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 exphalion date, and at the lime of renewal any new
criteria in the Wisconsin Administrative Code will be applicabie.
3. All revisions to this permit must be approved by the pe n6t issuing authority.
4. Changes in ownership or plumber requires a Sanitary P^rmit Transfe,"Pen-wal Fo*m 6399) to be
submitted to the county prior to installation.
5. Onsite etvaje systems must be properly maintained. ? ta!-4 s) must be a licer, t;vd
pumper whenever necessary, usually every 2 to 3 years,
6. If you have questions concerning your onsite sewage r;y~, ern, contact your local code wn-inistrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. 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 Dwell ng.
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 requestr:l in ##1-7. -
VII. Tank ^,formation. Fill in the capacity of ,/wry new and/or exr,t~ r tank .t tli total gallons number of
tanks and manufacturer's name Indir,-v'.a prefab or site constru, > ;a;* material. (ctrl to or all
septic, pump/siphon and holding t,:nks for this system. Check r>.x, r approvai ; r y i' tariks, received
experirmr n.tal product approval from Di..-Pad?.
Vill. Responsibility statement. installines plumber is to fill in nw e with aJr ror rioie prefix (e.g.
MP, etc.), address and phone nun ::,c; r Plumber must siosl
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not sr-nailer than 8'f2 x 1 ir?rh mlr/ t be submitted to the county. The
puns mcssi include the following olot ry°a.n, drawn to sc. r,- ,;n r plete dime.ions. r.t:on of
ho;ding tank(s). septic tank(r! or tither treatme it tanks; ar vells; wate,- to ter service;
streams and lakes, pump .r pho,i tanks; distribution boxe> ~,rr c;•nficm sys'erns r,,piE,_f-iY~ent system
areas; and }h li)Cation of 'h a t ?Served; B) horizont6? tidal '.1eY34i7r rFf~?r '~r" )0`Mts'
C) complete specifications for pumps and controls; dose is -?lr vatioin drfferenc fr, ;,i_n loss; pump
performance cu(ve; pump model and pump manufacturer; 0) cro s section of the soil absorption system if
-,required by jh6'county; E) foil test data on x-115 form; and F) allii$ing inform ti
\ ork:+ s
-
- - - - - - - - - - - - - - - - - - - - -
GROUNDWATER S!URCHAF: GE
1983 Wisconsin Act 410 inciuded the creation of sur-,harass (fos ; fo,r , r:: n-,;;, -r of
regulated practices which ca,i effect g•riundwater. TThe nsonies collected thrc l.igh t-iese s_ircharg S arf used f[~{ fmltJlc' r Y= q:' ny
wager , ti:r~fiamrna#ion rnves ratY,ns anr± esta
" iftanrjarct
SBD-6398 (R.11/88)
eLV I PLAN
PR`OJECT-oA~lh lelPwle ADDRESS
/4,5 1141S141T,,Z7 N/R l W TOWN COUNTY
MPRS yron Bird Jr. 3318 DATE
BEDROOM CLASS PERC_,j-7_ CONVENTIONAL,gIN-GROUN ESSURE
CONVENTIONAL LIFT MOUND_ HOLDING TANK
SEPTIC TANK SIZE a~ `'FT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA G~ PERC RATE BED SIZE
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark ~u 5<
17 Borehole Q Well Scale = Feet
O Perc Hole System Elevation 3
Vent
12"
Gradp
TYPAR COVERING
• ~ 2"
12" 3' 4 6' O 3'
I Sewer Rock
6" ~r 1.2'
I
n~ ~ max.
(6
LJ1
7y°°
Wleconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S-~ • e'v'0 r
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. C7o20 0 - 6
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT 114. f~ 1/4,S j T N,R E
PROPERTY OWNER':S ILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
jl~ Q,
O
CITY, TAE ZIP COPE PHONE NU B R []CITY []VILLAGE OWN N AR ST ROAD
bxis _0 q(3 V_ (k Stj 9 Y\ Lo yi _j
[ ] New Construction Use rA Residential / Number of bedrooms [ ] Addition to existing building
] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate ~Zbed, gpd/ft2__,,_ktrench, gpd/ft2
Absorption area required bed, ft2 j trench, ft2 Maximum design loading rate ----,,7 bed, gpd/ft2 • gtrench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system TSV110 TIONAL MOUND 7SEl ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem U S❑ U U JaZ El U ❑ S ❑ S 'Jau SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
• i~\\ti tiii
:n.
N'••. titii'~
{ti.i4{Vi44i
F7
Ground 3 T • J , 45'
elev.
`Depth to
limiting
factor ,
y
3•
Remarks:
Boring #
w
:
,o, 4,14 64"
Ground 69 S
4elev.
Depth to
limiting
factor
. 2 Remarks:
CST Name:-Please Print f! Phone:
/,S' ~ X76 l
Address:
lt// S oa/
Signature: Date: CST Number:
/ 7
PROPERTYOWNERr/tn SOIL DESCRIPTION REPORT Pageot-
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Botnclary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw&
c r
Ground - 0 S G"-~-
~1T~ft.
Depth to
limiting
factor
Remarks:
Boring #
w #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
e'
®
A te` a-It
a 7<- t; ):le
r
3U
' a
i
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS: FIRE NO:_ J
LOCATION: /~!!G 1/4, 1/4, SEC.--/-/ T1z2~N-R W
TOWN OF: c/Sp ST.-CROIX COUNTY ,X
SUBDIVISION: LOT NO.
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 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 to
help with the cost of the 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 the St. Croix County
Zoning 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 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. Certification from will be sent approximately
30 days prior to three year expiration.
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 form must be completed and returned to the St.
Croix County Zoning Officer within 30 days of the three year
expiration date.
SIGNED:
I.
DATE :
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
STC -loo .
This application form is to be completed in full and signed b
the OWIlcr(s) of the property being developed. Any inadequacies
will only result in delays of the
development be intended for resale byt owneranc nce. Should this tractor, louse), then a second form should be retained and completed(w
spec
hen
the property is sold and submitted to this office with the
appropriate_deed-recording_--- -
Owner of property
n
Location of property_,VZ 114 ~1/4, Section, T a~ N-R/_W
Township
Nailing address
h
Address of site
subdivision name
Lot no.
Other homes on
property? yes,.•~_No
Previous owner of property Jj
Total size of
parcel ~
Date parcel was created _
Are all corners and lot lines identifiable?
Yes No
is this property being d
ve op
Q ed
for
~Z (spec house) ? Yes No
volume-~$nd page Number -4gas recorded. with the Register
of Deeds.
I14CLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARFUUITY DLED which includes a DOCUMENT NURBER, VOLUME AND PAGE,
11U1•iDLR & THE SEAL OF THE ItEGISTLI OF DEEDS.
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 ascribed in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document Teo.
own the proposed site for the Sawa ~ and that I (we) presently
o dis
bta' g osa
e l system or I we)
fined an easement, to run the above described p operty,(for
the construction of said system, and the same has been duly
recorded in the office of county Register of deeds as Document
No. r
Signature of applicant
Co-appl cant
Date of signature
~ ~ ~ Date of signature
1 ~ , t w
n I I1 ~O•
~J~I<i_ IY -000
-6 0
a
d6 -10d
i
%~fa9 /9 103
I
RRP*T Or IPTSPECTION--INDIVIDUAL SM4ACE DISPOSAL SYSTEM
/ Sanitary Permit v~ 7
• , r.. State Septic
.,.AUE TOWNSHIP W--, ~ce
• t. Croix, County
SEPTIC TA' 11
• Size Zd= gallons. `umber of Compartments
04.0
Distance From: Tell ^
- .51
_ ft. 12% or greater slope tAo-fl.
- Building ft. f
Wetlands
21 i.S~ Iiighwater ~4 ft.
DISPOSAL SYSTEM x Tile Field or Seepage Pit(s)
(Distance From: Well t• 12% or greater slope /fjwft
3 Building = ft. Wetlands f
HiFhwater _ ft. .
Total length of lines /dt ft. Number of lines. Length of
each line _Ft. Distance between lines G ft. Width of the
trench ft. Total absorption area t/0_ _sq. ft. Depth
of rock below rile ~in. Depth of rock over the Z-- in.. Cover
aver.xock f~ Depth of tile below grade
in. Slope of
trench in per 100 ft. Depth to Bedrock ___ft. Depth to
ground water
ft.
PITS
Number of wits Ou i iameter ft. Depth below inlet
ft. Gravel around j ' yes no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
Square feet of seepage ni- ea required .
Inspected b O-A4L-Title
Approved Date AAA Q 1977$
Rejected Date 197
PLB6 State and County State Permit #
Permit Application County Per 't #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. J~OWNER OF PROPERTY / Mailing Address:
U T/ L,---?/ U,Q~ Ofv GlIS ,S ~o to
B. LOCATION: Y4Section f TV N, /4 1X (or) (D Lot* City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ALU6so/U
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family -X Duplex No. of Bedrooms ?j No. of Persons::-,_
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bath rooms-/-O~-p
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY /dXJO Total gallons No. of tanks /
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement- Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _ 2)/3) /_Total Absorb Area (p/S sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length Width Depth F.P Tile Depth 3 (p" No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land L 2 e L 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 CertiX Soil //Tester,
NAME /VTiy0/(/C), C.S.T. # ~7 and other information
obtained from G owner/buo'deF)
Plumber's Signature P/MPRSW# Phone #:W
2- 2-
Plumber's Address w
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
}-~oLD~ N ~
1,60 {1~US
I
n
/51
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Do Not Write in Space Below p FOR DEPARTMENT USE ONLY 7~
Date of Application 7 7 0 Fees Paid: State /0,001 Coun Dat
Permit Issued/Rejeeted (date) Jr l,: _Issuing Agent Name
41
Inspection Yes__,~(No Valid* Date Rec'd
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 6/1 /76