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HomeMy WebLinkAbout040-1196-50-000 -0 0 -0 0 o M C C O O a 0 ~ I ~ I I 0 N I I ti s I I ~ I ~ I w I € I a a~i aNi co c Z c z 'o LL c Li c °r-' 0 o rn I E ¢ w I Cl) c) z of Q' E ° € ° z y y d m C14 W o. m a m 0 0 O Z:t c c w o d z a ° o OR F- Z Z E '2 E N a) 3 a) 7 N 5) CL = n (D Q) D y C U) CD ~ C C y C U) 0 •N a O o (n c c L) Q Q zmz z co z N r o z I CD C C C c m E N ~T V i N ~ a) d d - y N 0) 75 O C. l N C C. r+ r N C CO H a) ` y d O W a! N N O t o G G a ° p i6 C O a 'a E ~p N 0 a- co EL CD 5 0 •N a) aaa y 00 m0 IL in N J U c rn rn ai rn rn } ° } a CO :z C2 ~ S N N Q M f` O E = co O .J O O 'O ° ° O d ml c d C m N c U 'O N N CA _N J 'd N N O a) 2 •o 2 Q in f6 e~~ Q Q l~l C C 7 sa ~O r.+ O N O ` _ LO C C 7 a) -2 -2 OC 4 ° co oi a s c n' (M U? CO ° o c r a p o°i o ° c CO m c Z G E E as 5 N 0) 4) 00 5 0 0 °D o m d o o o a`) ° C • ~ ~ ~ O H CJ N Z ~ 2 2 ~ fn ~ O Z N ~ ~ (n ri E EIL IL d • ad rr~~ E m c `~1 A Vaal ',0Uu l0U)u FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER N-E-1 l 1 ' l Q TOWNSHIP ~(ZQ SECTION _j T~N-R I WQ 'I ADDRESS__ S 8 L U N & LAN e ST. CROIX COUNTY, WISCONSIN SUBDIVISION ti) ~ n K1, CoU Kt LOTJ! LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I 3 ll II O U 8a' BSI ► Ruti VA►ve a 1 4 I 1 y a I v e ~~xy - -o '0 1 L 31 55 9c~. ~ y 38 R W BENCHMARK: Elevation and description: Tn O V Pti 0 f i p ~er~ S~~~Cm Alternate benchmark SEPTIC TANK:Manufacturer: Liqu~. Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front , Side , Rear Ft. 1 No. of feet from: Well Gag I , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side_, Rear-Ft. Distance from: Well Building 71, . .7 Il (a 0 SOIL ABSORPTION SYSTEM 18 -_r0 ~~O (f ~a g a S U~ Bed: Trench: Seepage Pit: Width: M Length 7 O Number of Lines: 3 Area Built Exist. Grade Elev. Proposed Final Grade Elev. ,lam Fill depth to top of pipe : _ 40~ No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from well:_LLL_No. feet from building_ ~p 5 HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE : PLUMBER ON JOB : LICENSE NUMBER: 6/90:cj III I i ~ I ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT n FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that rnI have inspected the septic tank presently serving the W-) I P)6I ~K residence located at: S~ 1/4,~ 1/4, Sec. TJ~ N, R W, Town of TKO U4 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 gi Did flow back occur from absorption system? Yes No4(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): Age of Tank (if known): I~ ~KS r (Si ature) (Name) Please Print M19KSO 390Y (Title) (License Number) as ~ ~ (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 `J Its VG~Q~ SDK Signature &IL~Apy/MPRS Ul 5/88 aj Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ~LaborandHumanRelations Safety and Buildings Division INSPECTION REPORT St. Croix SE,NE, 4.28119W F Sanitary Permit No.: GENERAL INFORMATION Lot #17 - ig A 1 TOPE RMIT) Lundy Lane 149149 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Neil Miller Troy CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 889 TANK INFORMATION ELEVATION DATA -7 it TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/lvit Inlet t TANK SETBACK INFORMATION St/ FA Outlet 7 g7' 9, Vent irito ntake ROAD Dt Inlet TANK TO P / L WELL BLDG. A Ar Septic It l NA Dt Bottom Dosi NA Header /`hAa+~- < <3 g~, Aeration NA Dist. Pipe I Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade - z,o I~ Manufacturer Demand Ila 75 Model Number GPM f" TDH Lift Friction System Ft CIZ (1' (D 9119 Loss mead l/R.~,i 4/. Forcemain Length Did. Dist. To Well S. . C,,Jeer L(o U SOIL ABSORPTION SYSTEM BED/TRENCH Width f Len r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS th g U DI SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING nu acturer. SETBACK - INFORMATION Ty CHAMBER peO e(~Ks 1 i Mode Number: System: y 4 OR UNIT DISTRIBUTION SYSTEM Header oovm field Distribution Pipe(s) / / x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 2-1- Dia. AL Spacing / > 7 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over (p Depth Over (p xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center . Bed /Trench Edges 2' r Topsoil C] Yes ❑ No E] Yes E] No COMMENTS: (Include code discrepancies persons present, etc.) - L c. s r . Gx ='t. w~ t i IY~I G L ` k' ~ rrt l~ , t+ t X . S T ®~C ,Qe c n 3 sly~~ Plan revision required? ❑ Yes ❑ No Use other side for additional information.' SBD 710 R jqj5/91_)y_-n r' Date inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH " SANITARY PERMIT NUMBER: : 3 CtZ 4,6' 7 irno- , e -1 41Z ? i 3 I III SANITARY PERMIT APPLICATION =;~DRIL HR c ouNTYIn accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY 2PERMI 8% -Attach complete plans (to the county copy only) for the system, on paper not less than ~ x 11 inches in size. ❑ ihac if revisito prev us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY WNER PROPERTY LOCATION ~C, N,R E(or)W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ( ~u d Lew l S C` Z CODE PHONE NU BER SUBDIVISIOIN MEQR CS UTIER CITY, STATE III. TYPE OF BUILDING: (Check one) ❑ State Owned O VILLAGE h NEAREST ROAD N OF: ~U UA)v ❑ Public IR1 or 2 Fam. Dwelling- # of bedrooms P EL TAX NUMBERW _j Ill. BUILDING USE: (if building type is public, check all that apply) o 1 ❑ Apt/Condo 0 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 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. ~RReplacement 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 rv 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.) (G Is/day/sq. ft.) (Min./inch) ELEVATION C5 .4 `1!50 DO 3 3 V Feet C.Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New P-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber El 1 1:1 1:1 1:1 1 1:1 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 Signatu e: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Stree City, State, Zip Code): 1s o t,~ /11I GCS IX. COUNTYIDEPARTMEN USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued, Issuing gent Signa ure No S ps ,Pj7Approved El Owner Given Initial Surcharge Fee) p Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber APPLICATION FOR SANITARY PERMIT STC - 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. Owner of property Location of property _1/~ /9, Section , T,;;28 N-R W Township, Mailing address Address of site E- .r s iflda - G~~~~r-~ Subdivision name Lot number / Previous owner of property ~.4t sty, +~y 1~.~►~d.~ /7.Q~,p-r Total size of parcel "-Z._.35.n~ocs Date parcel was created /.97.9 Are all corners and lot lines identifiable? k- es No Is this property being developed for resale (spec house)? Yes Se No Volume A'76) and Page Number c2a? 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. 3 ?6 76S ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with 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 N 21, 7. 4m Sign' ure of Owner ignature of Co-Owner (If Applicable) n t Date of-Signature Date a Signature SEPTIC TANK MAINTENANCE AGREEMENT ~ St. Croix County ~ OWNER/ BUYER Fire tJumber fsi ROUTE/BOX NUMBER d CITY/STATE ZIP r* Section, TZN, RW, PROPERTY LOCATION : '.',e&~4 4 k Town of St. Croix County, SubdivisioLot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licens'ed' 's'e' tic tank pumper. What you put into the system can affect t e unct on o, t e septic tank as a treat- ment'stage in the waste disposal system. St. Croix Count residents may be eligible to recieve a grant for system, a maximum of 60% of the cost-of replacement of o failing whic was in operation prior to-July 1, 1978. St. Croix County accepted this perrogram in August of 1980, with the requirement that owners of all new sys't*ems agree to keep their system properly maintained. 0perty owner agrees to. submit to St. Croix County Zoning a ceretification form , signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or.a licensed pumper veri- fying in fying that (1) the on-site wastewater disposal system proper operating condition and •(2).after inspection and pumping (if nec- essary), septic-.tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year-expiration. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as.set by the Wisconsin Depart- : ment Natural Resoures. and returned to the of the three year expiration. date. SIGNED DATE & St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. f DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 HUMAN RELATIONS N WI53707 HUMAN (1-163.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/Ddl1A1F2tPF~C Y: OT NO.:BLK. NO.: SUBDIVISION NAME: GO- 1/404/ /T2SrN/R /T1 (Or) J iyu l'GI e CO TY: O NER'S BUYER N E: MAILING ADDRES : /awe 115-U)~ U USE DATES OBS RVATIONS MADE NO.BEDRMS,: COMM AL DESCRIPTION: PROFIL S RIP I NS: PER IOM ESTS: Residence ~ ❑ New ~eplace COL RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: . Q ND-PRESSURE: SYSTEM-INLHO ~ LDING~ : RECO ENDED SYSTEM: bona PS ~jk~'Jy U S S A If Percolation Tests are NOT required DESIGN RATE: > If any portion of the tested area is in the under s.H63.09(5)(b), indicate: 5 Floodplain, indicate Floodplain elevation: i I :l PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER F SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH LEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-' b ~j~, ~7 s ~67~~~s•~ . L y2 ~n S .67-e.- .s 3,.0 S / 6 B-Z >`~o B- V3 13- 13- 13- PERCOLATION TESTS TEST DEPT ATER IN HOLE TEST TIME DROP IN WATER L VEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH D < Z P- 1 7 P- 2 / 33 P_ S 3 3 c ~,y g P - ~ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 5-~ 0 $ V )i :.a.... _ a _ ~ I 4 t s ©G x ~ = f i ~ ~ 9 s 1 , ~ i i 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS W /RE C PLETED ON: felt, 4 R r, GJ~ ADD E SS: CERT FICA O NUMBER: PHONE NUMBER (optional): L3 G' 60 3 -7- A rS3 CST R iSIG/Z DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - Q.L. - 6 7 PLOTA N , R 0 S S 5 EC -1-1 ICI , l e _ IV_.. A M E ~77 f3c) >7f-.,, 'NAME )t; L MA s A. I ON __~L .._R- cu ~ ' . C E N S E = - 3 q ~ '1__._.. PL 0 MAP J ~V WIP r1 It GgtJ ' 1, vtS l xn j Q' T r • ~ fig' S u ~ r.~ y rJ UT~A t rV J FRESH AIR INLETS AND OBSERVATION PI.PE SECTION f .Approved Vent Cap Minimum 12" Above g9- Final rraS~G A" Cast Iron Above To Final Grade. Vent Pipe Marsh Hay Or Synthetic Covering Min. 2" Aggr.egl-H Over Pipe I Distribution Tee Pipe Aggregate Per-f.orated Pipe Delow Beneath Pipe ,eCoupling Terminating 1\ 11 Bottom of System Q zo tr. A T'FIRST ADDITION )F SECTION 49 T28N. R19W. TOWN OF TR NTY,WISCONSIN c HIGH c RIDGE I \ I DS i I N 87°36 '39° E A' o 035\"E 215.18' 7 157.60' S 4 056~~ o o N87°03'22"E N6 X00 ,spa I2 AYH ~g 1` cn 203.05 2 to w 176° 134 6+ 2 'a 14 4j /1O ° 0 GI M p 06 M h Z 16 !2 , titi ~~J ti0 -17 2 .90 ACRES o O 2,73 ACRES c I titi ` O h o° s 5 S V6 / / 66'• 203°15 204 00 h / 15, /SS0030 -190, 0/3s / h '9"., 129.14 41 /0 VIEW- 165.46' h I6 0 ?o o Fs 09 cy 6 S/ 4 155003 w to 616 18 29 3.90 ACRES N 3.59 ACRES M N N 0 19 3 N 2.40 ACRES ° V, to N N ,ten m • A6 Q' co N o 6 Z r- 3 'S0 ►Og' ~ ~ • AS BUILT 'SANITARY SYSTEM REPORT R , TOLTNSHIP SEC. T2 ST. CROIX COUt~ WISCONS N. , 51 ADM 0' Agdd2:~e ~IDTVlSIO t LOTJ-,2LOT SIZE PLAN VIEW 'DistaEnce.s b 4,imbn6ions to zeet requirements of H62.20 SHC, MRY'THING WITHIN 100 FEET OF SYSTEH t « I / WV -VI t "T- T 00, l ~ ti - b ~di6at , a e lorthi Atro ( SC' L EEL tL4 CONCRETE $T ~TTY TANKM GRf NCB. A rings on cover Depth DRY WELL',_„ S No,, ,qt _ width le'n'gth area no. of i.ine $ wfdtt~;W length, area-^~~~ « dep to op of pipe rr 1Lr A 'tir-QU 4 TEE Alu'.tf A DUiLT...w Claimer:.,The inspection of this system by St. Croix County does not imply complete . 14,01ionce With State Administrative Codes. There are otter areas that it is not possible ;nepeet,et,''this point of constru6ti:on. St. Croix County assumes no liability for _`.4em opexa,tion. However, if failure is noted the County will mAk+e~everq effort Co rMine cause of failure. ASES MD OILS SHOULD' NOT BE DISPOSED THROUGH THIS SYST01. -`INSPECTOR DATED 7 PLUMBER ON i LICENSE NUMBER 9* AZ z REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM San.itah.y Pehm.i.t C__2 State Septic 610 NAME(Ie" Township ~ St. Croix County Location section SEPTIC TANK Size/2,0 0 gattonz. Numb en o6 Compantmentz Distance Fnom: Wet 12% on greaten ztope a o Bu.itd.ing /0 it. wettands 6t. H.ighwaten it. DISPOSAL SYSTEM Distance Fnom: Wet sz-f- it. 12% on greaten .stopeJQP it. Bu.itd.ing,?,5-Iit. Wettands Ft. H.ighwa.Len it. FIELD DIMENSIONS: Width o6 theneh~it. Depth og noeft below t.ite_z_zL.in. Length of each tine( it. Depth o6 rock oven t.ite L .in. Numbers o6 tines Depth o4 t.ite below gradeZ ~.in. Totat .length o6 tines it. Stope of tneneh Z' .in pen 100 it. Distance between tinez--Lat. Depth to bedrock ~ • Totat abdonbt.ion anea_Ag_~_6t2 Depth to gnoundwaten-&-5t. Requ.ined area / S- it2 Type of Coven: ape n Straw PIT DIMENSIONS: Number o6 pits Gnavet around p.itzs yea no Outside d.iamete 6 Depth below .intet it. 2 Totat abdonbt.ion area it A Aa equined it2 INSPECTED BY; TITLE APPROVED DATE_ 19 7_~. REJECTED DATE 197. 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: 45-e'14, '/a, Section A, TIN, R ff E (or)aV Township or Municipality Lot No., Blo~11 o. County L T /x Subdivisio Name Owner's Name: )n n InA _ Mailing Address: kI TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT n DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS NVAle K nmilecO SOIL MAP SHEET SOIL YPE 0AAM i 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- ) SEE SOIJOCN65 No T .6 4)0 1 g E, r\ P 3 y~ 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) N ~ a L / r' ~ f L r' i S •J 1 C/8 Aft mt~- 7 RK N. S L. ~ AN, 141. WtCrA rv c O IqUKA9,13.6, L. T L Z. -4 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitabIVreas. ndicat nu ber of square feet of absorption area needed for building type and occupancy. j~2 45 40 f Indicate scale or distances. Give horizontal and vertical reference points. I e slope. wl 77 G \ \ 1. I I I I t 1 N f ~N ~Lwl Le a o~ t 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 lief. Name (print) Certification No. . Address Name of installer if known 1L. CST Signature COPY A -LOCAL AUTHORITY • State Permit # 0 0 P L 16 7 State and County Permit Application County Permit # ® for Private Domestic Sewage Systems County s~~1='QQI *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: aobf) &M (20QC7- N GL is ~ P•e~ B. LOCATION: Z`P'/4 6 Section !t( , T ' $ N, R _Z_q E (or) 10 Lot# 17 City Subdivision Name, nearest road, lake or landmark Blk# Village Township 6~ 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 NO # of Bathrooms Automatic Washer Y- YES NO Other (specify) E. SEPTIC TANK CAPACITY &C Total gallons No. of tanks % *Holding tank capacity Total gallons No. of tanks New Installation Addition _ Replacement _ Prefab Concrete .X *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) qE9D 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 A L1. `Tile Depth 6 -31) No. of Lines_ Seepage Pit: Inside dia Liquid Depth Tile Size y~ a Percent slope of land met 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 ster, NAME C.S.T. # and other information obtained from * Li (a owner/builde _ Plumber's Signature MP/MPRSW# Phone Plumber's Address AP L.S -T-V PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). 10, \Cj may' Do Not Write in Spa a Below FOR DEPARTMENT USE ONLY Date of Application Fees Paid: State /0'OD Cou Date o~ -Jff 4K4 f -'o Permit Issued/•Re}eeled (date) -Issuing Agent Na Inspection Yes NoPY Valid# Date Recd 1. county (whits co ) 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