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Form - S T C - 106
AS BUILT SA IT�RY SYSTEM r.EPORT
SR �i �h %�i i� _ TOWNSHIP 1V ?d��r5 c SEC. T , N-R H
OWNER �
ADDRESS CtIOIX COUuTT, WISCONSIN
SUBDIVISION _ �- LOr - LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERY 11111G WITHIN 100 FEET OF SYSTEM
nn�J
4
la�r
• INDICATE NORTH ARROW
.. /37
BRNCNM RK: Describe the vertlr.nl reference rnint fused
,
Elwation of vertical reference potnt: � pc Proposed slope at site:
89"IC TANK: Manufacturer: _ _ /CJc e /I 5 L.IquJd Capacity: —
/"� �
Number of tinge used: c Tank mnnhute cover elevation:
( _
GJ,�b Tank Inlet Elevation: Tank OuLl%.t. Urvation:
Number of feet from near, I li-,id: Front,0. -•,ORear, 0___ feet
�OFrom nearest peuE,c.c. l.lne : Front , -Jr,O Rear,O feet
PUMP CIDER
Liquid Capacity:
Manufacturer: pump Size
pump Model: Pump/Siphon Manufacturer:
Bottom of tank elevations
Elevation of inlets
pump off switch elevation:
Cnllons per cycle:
Alarm Switch Type t
Alarm Manufacturer: O
Number of feet
from nearest property line: Front. O Side, OR*ars
Number of feet from well:
, Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION .SYSTEM
Bed: Trench:
/ LenEh:
Number of Lines: _7 Area Built:
Widths
Fill depth to top of pipe:
property line: Front. Side, O Rear
•OFt `��
Number of feet from nearest prop y
Number of feet from well:
Number of feet from building:
(Include distances on plot plan). 7�Gd � l�5• 5
SEEPAGE PIT -
Diameters
Sizes Number of pitst
Bottom of eaepee88 pit elevationt
Liquid depth:
Area Built:
been used on any of the above soil
gas either a drop box O or distribution box O
absorbtion sytems? (Check one).
HOLDING TANK
Capacity:
Manufacturer:
Number of rings usedt Elevation of bottom of tanks
Elevation of inlet: Front, Side, Rear,
Number of feet from nearest property line r
O O O
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Ala= Manufacturer:..
. o
Inspector: _ .
Plumber on job:
Dated t ��� ���---
License Number:
3/64ssj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR&HUMAN RELATIONS DIVISION
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
M ISON, 15 707 State Plan I.D.Number:
NE o,S e,,,S�ec. 29 ,T31-RI9 St
Town of N. Somerset ❑ CONVENTIONAL ❑ ALTERATIVE assigned)
1 h Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Brian Parnell lBox 176 Somprget q-/ _
BENQ MARK(Permanent reference point-)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
B Bird Jr
r1
SEPTIC TANK/HOLDING TANK:
MANUFAC RER: LIQUID CAPACITY: TANK INLET IJI EV.: TANK OUTLET ELEV: WARNING LABEL LOCKING COVER
PRO VID PROVIDED: ,�-
yr 1' ✓ �'/' ES ❑NO ❑YES-CJ NO
BEDDING: VEN VEJZIT MA7t:; HIGH WATER NUMBER O ROAD: PROPERTY 7WE-
EYE BUILDING: VENT TO FRESH
(`►,,, ,) LINE: AIR INLET:
S �NO / ` A❑YES 2TNO NEAREST—► �V D
DOSING CHAMBER:
MANUFACTURER: TBEDDING: LIQUID CAPACITY: PUMP MODE PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
ES ❑NO [DYES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUVatdepth TR SOP ATI NAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF Y O NEAREST—�
SOIL ABSORPTION SYSTEM. Check the soil moistur f pl Ing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire,cons uction shall asellintil MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE$PACING: COVER INSIDE DIA.: #PITS: LIQUID
�✓ TRENCHES: / MT'I=REAL: PIT �. DEPT ,
DIMENSIONS ✓) rp ;L
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BE L0 PIPES: ABOVE COVER: Ey,EV.INLF;rT ELEV.END: c� PIPES. FEET FROM LIN AIR INL-7ET:-�y
'7 S 1=1)-7 / � NEAREST♦ /`
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO OF LATERAL SPACING: I GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEVATION AND ELEV. ELEV.: DIA.: ELEV.: PIPES: DA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
OMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: :IF:EET BER OF PROPERTY WELL: BUILDING:
LINE:
t� ❑YES ❑NO ❑YES ❑NO RES TO—►
G
r,
Sketch System on Retain in county file for audit.
Reverse Side. TU E: 01 TITLE:
SBD-6710(R.06/88) r
SANITARY PERMIT APPLICATION
•L �ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY `
–Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARY PERMIT#
8%x 11 inches in size.
—See reverse Sld@ for 11StrUCtIOfS for Completing this application. El C rf is u—r e f o
us application
STATE PLAN I.D.NUMBER
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. � �
PROPERTY WNER / PROPERTY LOCATION
rn c/ %a 510-Y4, S� T , N, R , E
PROPERTY OWNE 'S MAILING ADDRESS LOT# BLOCK#
CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) ❑State Owned V LLAGE' 1 NEAREST ROAD
❑ Public 4/ne� �/ 137W
�1 Or 2 Fam.Dwelling of bedrooms R EL TAX NUMBER(
III. BUILDING USE: (If building type is public,check all that apply) �L 1—.2
O
1 El 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. ugh New 2. ❑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
�`5 d " G :5 Feet g
VII. TANK CAPACITY /, Feet
in aallons Total #of Prefab. Site Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
Lift Pump Tank/Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
1,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:
PlunfWs Address(Street,City,State,Zip Code):
IX. COUNTY11 USE ONLY
❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued ssuin Agent Signature(No Stamps)
Approved ❑ Owner Given Initial / JQ Surcharge Fee)
Adverse ermin lion — —�
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 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 licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator 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. 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 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.
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% 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.
GROU14DWATER 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.
SBD-6398(R.11/88)
• APPLICATION FOR SANITARY PERMIT
ETC - 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 r ► Un / 6t Y-ne//
Location of property -S�- 1/4 Al )E 1/4, Section 2� , T � ( N-R.�? V
Township S'd �e ,-Se )-
Nailing address �o a' 176
Address of site S o r;-2 f/-s- f
Subdivision name
Lot number (�
Previous owner of property (f y hccvS f
Total slse of parcel
Date parcel was created Ina,Y f Are all corners and lot lines identifiable? . .Yes No
Is this property being developed for resale (spec house)? Yes No
Volume and Page Number as recorded with the Register of Deeds.
-------------------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and
the SBAL OF THE REGISTER OF DEEDS. In addition, a certified survey, 1f '
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(Ve) certify that all statements on this form are true to the beat 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 dead recorded n the Office of
the County Register of Deeds as Document No. 3-77 7•x'3 ; 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 bee 1 recorded in the Office
of the County Reg ter of Deeds, as Document Ho. 777 3 ) .
Signature of Owner Signature of Co-Ownet (If Applicable)
-_1d-- / Y
Date of Signature Date of Signature
DOCUMENT NO. [�� C A^E STATE BAR OF WISCONSIN—FORM 2
"VOL 3Ny,�y o r� WARRANTY DEED
r THIS SPACE RESERVED FOR RECORDING DATA
,,, REGISTERS OFFICE
ST. Mix co., WI&
Rec'd. for Record Rth 24th c
conveys and warrants t day o �� —A.D. 19_82 I
at 11: 0 A.
X 512 5 '� G o m1�IrLYI X
WO�far of Deed. (�
RETURN TO
the following described real estate in St. Croix County,
State of Wisconsin:
Tax Key No.
All that p art of the Southeast Quarter (SF ) of Section Twenty-nine (29) ,
Township Thirty-one (31) North, of Range Nineteen (19) �"est, described !'
as follows: Commence at the Northeast corner of the Southeast Quarter
of the Southeast Quarter(SFl of SE4) of Section 29 , Township 31 North,
of Range 19 west; thence ',,'est along the North line of said Southeast
Quarter of` the Southeast Quarter (SE! of SFI ) for 41.3 feet to the i!
point of beginning of this description; thence Northerly by a deflection
angle of 92 degrees 30 ' along the centerline 6f North and South Township it
Road for 127 feet; thence West for 2154.7 feet; thence South at 90 degrees i)
for 276.6 feet to its intersection with the centerline of Northeasterly
and Southwesterly Township Road; thence Northeasterly along said
centerline of Northeasterly and southwesterly Township Road for 317 feet
to its intersection with the centerline of North and South Township
Road; thence Northerly along said centerline of North and South Township
Road for 8 feet to the point of beginning; oontaining 1-3 acres, more or
less. Subject to the right of way of Township Roads.
This -5 na homestead property. ►. j
(is) (is not)
Exception to warranties:
EXEMPT
Dated this day of 14d i 19 I
�I
(SEAL) (SEAL)
arYh� �, k v1 a u1 r A c. (SEAL) (SEAL)
_ P -A t 2-4 e 1.I
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this day of STATE OF WISCONSIN
19 SS. �+
st. Croix County.
Personally came before me, this 211th day of
* May the above named
TITLE: MEMBER STATE BAR OF WISCONSIN Yvonne Parkhurst
(If not,
authorized by §706.06, Wis. Stats.)
1 I
This instrument was drafted by
me known to be"Ihf ee�soil ''qho executed the fore-
ing instrument kn eifttt�
(Signatures may be authenticated or acknowledged. Both * mee 01C`DSioe1la4 G+
are not necessary.) NolAry Public ' • r +� County, Wis.
My Commission�ts,`eennandht. llf' t -state expiration
date: +a�,�o i....• 1985
WARRANTY DEED—STATE BAR OF WISCONSIN, FORM NO. 2-1977 �� wd.rca i
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER lam` �{u '1
ROUTE/BOX NUMBER Bo x. 76 FIRE N0`.'
�'t -erse � /S ZIP J `10�-
CITY/STATE p � /�' C� c�
PROPERTY LOCATION: 5'r- 1/4 (Y G 1/4, Section 2 l , T -3� N, R � / W,
Town of S 0 ��°- "� , St. Croix County,
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 for a MAXIMUM of
$3000 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
systems properly maintained.
The property owner agrees to submit to 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 form 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 Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNEDC��
DATE /
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969
)
HUMAN RELATIONS ` / MADISON,WI 53707
(ILHR 83.09(1) & Chapter 145)
L AT ECTION: O NSHIP UNICIPALITY: LOT NO.:BLK NO.: SUBDIVISION NAME:
Alb V4 V4. /T N/R/ E 1
COU T : MAILING ADDRESS: /
lf/Cl/ a/'" O 7� C�/y�O'I" •G� ��✓/ r I a►Z.S
USE DATES OBSERVATIONS MADE ;20
NO. EDRMS.: COMM FI IAL DESCRIPTION: A I TESTS:'
Residence XNew ❑Replace _
RATING:S=Site suitable for system U-Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional)
WS au s ou sou [IS u a s ®u 4,4 eoe
If Percolation Tests are NOT required DESIGN RATE: FFI y portion of the tested area is in the
under s. ILHR 83.09(5)Ibl,indicate: dplai n,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL QEPIH TQ E R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSE V T TO BEDROCK IF OBSERVED 1 EE ABBRV.ON CK.)
B- love fte_
B- y6
ot
B _$-
e-
__ c-e PERCOLATION TESTS
DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBEfIANIML AFTERSWELLING INTERVAL-MIN. P RI D 1 ERI00 2 03 PER INCH
P- 4t. �yc G
P.
P
P-
P-
P
PLOTPLAN: Show locatiori't 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.
SY TEM ELEVATION il
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(, th hereby certify that the soil tests reported on this for wrefreL made by 7 e 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 WERE COMPLETED ON:
ADDRESS CERTIFICATION NUMBER: PHONE NUMBER(optional):
17�6�J'_7.
CST SIGNAT RE:
j
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
GI IrHR-SBD8395`(R. 10/83) —OVER —
PLOT PLAN
PROJECT Url0rl 111 a w e ADDRESS p CGS • �o�
1/4,;• 1/4/$f/T / N/R/ W TOWN - ` COUNTY
MPRS Byron Bird Jr, 3318 DATE
BEDROOM CLASS PERC ,l CONVENTIONAL„ IN-GROI NFORESSURE
CONVENTIONAL LIFT MOUND_,HOLD G TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREAS PERC RATE BED SIZE /�'z
h6 Benchmark V.R.P. Assume Elevation 100' .
Location of Benchmark
* H.R.P.
M Borehole Q Well Scale = Feet
0 Perc Hole System Elevation �.
Uent
12'
ode
TYPAR COVERING _ ._ __ ____ _- ---____
2"
12' 3- 4 8' 4O 3'
I
6" Sewer Rock f
12' I
I ,
aM
i
G°
DEPA,RTM.€`'VT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LAPOR F.rIUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
LCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
(If assigned)
❑Holding Tank ❑ In-Ground Pressure ❑Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
B CH MARK(Permanent reference pomO DESCRIBE IF DIF ERENT FROM PLAN: REF.PT.ELEV: CST REF.PT.ELEV.:
V � � v
Name o Plumber: MP/MPRSW No.: County: Sanitary Permit Numba,::IV
✓ / V
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO OYES ❑NO
BEDDING: VENT DIA.: VENT MATL: HIGH WATER ;ROAD: PROPERTY r=7 BUILDING:,VE OTRESH
ALARM: L
INE'.
OYES ❑NO ❑YES ONO
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: 's.PRNE ERTV WELL. BUILDING. VENT TO FRESH
AIR INLET:
(DIFFERENCE BETWEEN
PUMP ON AND OFF) ❑YES ONO
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENCrH_ DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
, yg,WIDTH- LENGTH. NQ_OF DISTR.PIPE SPACING. COVER INSIDE DIA.. #PITS. LIQUID
MATERIAL' L�. DEPTH:
RAV L EPTH FILL DEPTH 111IST11,111F DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR ,� ROPE RTV WELL. BUILDING: VENT TO FREPIPES: T �^ LINE: AIR INLET:
BELOW PIPES ABOVE COVER. ELEV_ NLET ELEV.END:
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES NO
SOIL .`OVER. TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS.
DYES NO OY ES F-1 NO
DEPTH OVER TRENCH;BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. JSEEDFD MULCHED:
CENTER EDGES.
El YES 1:1 NO ❑YES ONO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH- LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
b TRENCHES:
r"u�r�u
MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
_T .ELEV.: ELEV. CIA, ELEV. PIPES. DIA.:
HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
� PLANS.
❑YES ❑NO DYES El NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: LINE. WELL: BUILDING:
[-]YES ❑NO 1DYES El NO
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE TITLE.
DILHR SBD 6710 (R.01/82)
PLB 67 State and County State Permit#
Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
t5 ar e., G(/• S
B. LOCATION: �'/4 s� '/4, Section �, T N, E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township 5A w$e.S Pr,T
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family L� Duplex No. of Bedrooms / No. of Persons__
D. SEPTIC TANK CAPACITY ZP721�-f2 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft.
New �� Replacement Alternate (Specify)
Seepage Trench:�NO.of Ling��Ft. 1`Vidth De I —Tile depth (top)—,,.,--No.of Trenches
Seepage Bed:�O Length— j�j Width-1�Depth )Tile depth (top) �No.of Lines Z--
Seepage Pit: Inside di meter Liquid Depth No.of Seepage Pits
Percent slope of land Distance from critical slope Sr
WATER SUPPLY: Private X Joint❑ Community ❑ Municipal ❑ __
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section 1-162.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified oil Tes r, � )
NAME /e--4 a A- � f/IJ,�I O �� � C.S.T. # and other information
obtained from —�' (owner/builder). g
Plumber's Signature MP/MPRSW# �d Phone # �6—
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State County Date
Permit Issued/Rejected (date) Issuing Agent Name
Inspection Yes No State Valid# Date Recd
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 7/1/78
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'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
DIVISION
I�DUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707
HUMAN RELATIONS
LOCATION: SECTION: p TOWNSHIP/MUNICIPALITY ����ION NAME:
E- 1/x /4 /T3/N/R (or)W MAI ING A
COUNTY: W R'S BUYER'S NA
USE 1�//' DATES OBSERVATIONS MADE
NO.BEDRMS.: COMM ER IAL DESCRIPTIO NS: R A TESTS:
�U tb r
esidence
F�A
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RATING:S=Site suitable for system U=Site unsuitable for system
r9s ONVENTIONAL: MOUNQD: IN-GROUND-PRESSURE: SYSTEM- N-FILLHOLDING TANK:RECOMMENDED SYSTEM:loptional)
�u f�J J CIS S �u S O SNU �G !/
If Percolation Tests are NOT requiATE:SYS EM L�. �. If any portion of the lot is in the
under s.H63.09(5) indicate: `// Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, OBSERVED E HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B LU '� Aft, -� s'. S/ g.4
B,5 rn IV e
B-
` PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD
P /1-0 I f
P f
P-
P_
P_ _
PLAN VIEW: 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 onthe plot plan. Show the surface elevation at all borings and the direction and percent
of land slop.
SYSTEM ELEVATION ;-
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(prin : TESTS WERE COMPLETED ON:
�G ~ S CERT73:CATION NUMB:O E NUMBER optional):
ADDRES : �-
CST AT E: v
DISTRIBUTION:Original-Local Authority,2nd page-Bureau of Plumbing,3rd page-Property Owner,4th page-Soil Tester.
DILHR-SBD-6395(N.03/81)