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Form — S T C — 106
AS BU1.LT SANITARY SYSTEt1 r.EPORT
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LO r LOT SIZE /b !T -
aveotvia�oN
PLAN VIEW
Distance• and dimes .ions to meet requirements of I•LHR 83
110W EVERY 1:11111G WITHIN 100 FEET OF SYSTEM
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INDICA?E NORTH JRROW
UNCIMMs Descrl".:e the verticnl reference roint used 60'se wflflj torn er1'09�
elevation of vertl al reference po lnt: Mo.o _ Proposed slope at site:
BUT= TANRs Menu ;acturer: PAW esl I'F'�QS�J..J•juJd Capacity: 4 060
r
Number of rinf-i used: Tank mnnhute, cover elevation:
Tank inlet El- ration: Tank OuL.i:_t. L.I.evation:
Number of fee, from nearr i r".1d: FronL,0 ."t. ^,O Rear, O feet
From nr_ Ceat• rL(.111 .t. i.111c : Fr,:�nL.( _) t•1r,0 Rear,O feet
J
pUMP CHAFER
Manufacturer: _ Liquid Capacity:
. Psaep Modal: _
Pump/Siphon Manufacturer: pump Site —
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation:
Cnllona per cycle:
Alarm Manufacturer:
Alarm Switch Type:
Number of feet from nearest property line: Front. O Side, O Rsar.O Ft._._,_,_
Number of feet from well:
, Number of feet from building:
(Include distances on plot plan).
hSOIL ABSORPTION 8YSTEM
Beds Trench
Width:
Lenith: Number of Lines: Built:
Fill depth to top of pipe:
.�_
Number of feet from nearest property line: Front, Side. Rear. It
O O O
Number of , fest from well.:
Number of feet from buildings
(Include distances on plot plan).
SEEPAGE PIT
Sizes
Number of pits: Diameters —�
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has sithei a drop box O or distribution box O been used on any of the above soil
absorbtioss sytems? (Check one).
HOLDING TANK
Manufacturer:
Capacity:
Number of rings used: —.---_ Elevation of bottom of tank:
Elevation of inlet:
Ft.�.
Number of feet from nearest property line: Front O Side, O Rear, O
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:..
Inspector: _ .
Dated% Plumber on job: _
License Number: _
3/84smj .
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
SW 4M§DISON,V� 0 14, T28-R19 7 St ate Plan l.D.Number:
WW eC
�y J ❑ CONVENTIONAL El ALTERATIVE (If assigned)
Town of Troy
Hwy 35 ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSP ECTION DATE:
Mark Duenow 4605 River Road Afton M (/—/ —d 1 '—o�f3
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: PrEF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Thomas Wang St. Croix 1
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL I
: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
I GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑YES ❑NO NEAREST---11111'
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDEDIA.: #PITS: LIQUID
BED/TRENCH TRENCHES: MATERIAL:. PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV.INLET:I ELEV.END: PIPES: FEET FROM LINE: AIR INLET:
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 I 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: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL:I NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEV.: ELEV: DIA.: ELEV: PIPES: DA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
E:1 YES E]NO ❑YES El NO NEAREST411"
.Q 11
/03,01
J72
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710(R.06/88)
SANITARY PERMIT APPLICATION COUFJY
In accord with ILHR 83.05,Wis.Adm.Code
STATE SANITARY PERMIT#
-Attach complete plans(to the county copy only)for the system,on paper not less than 14V6 V/
8%x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION.
P PERTY OWNER PROPERTY LOCATION
K t '/as't'ir) '/a,S R E(O
PROPERTY OWNER' AILING AD Rg �SS LOT# BLOCK#
t 'e
STATE ZIPJCODE PHONE NUMBER SUBDIVISION NA16®SM NUMBER
"f0 t do
II ). TYPE OF BUILDING: (Check one CITY NEA S D
El Owned ❑ VILLAGE: �� 3
❑ Public N 1 or 2 Fam. Dwelling-#of bedrooms� PARCEL TAX NUMBER(5)
III. BUILDING USE: (If building type is public,check all that apply) ON d
1 F-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. N New 2. El Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El
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 f /x 51 3 /
VI. ABSORPTION SYSTEM INFORMATION:
1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQU RED(sq.ft.) PROPOSE�D/(sq.ft.) (Gals/da /sq.ft.) (Min./inch) p ELEVATION
S Cf4/� �- I Q r 1/0 7 .7 5 Feet 49.d Feet
VII. TANK CAPACITY Site
in allons Total #of Plastic
Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel structed glass App
Tanks I Tanks
Septic Tank or Holding Tank UV es Ll
Lift 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): Plu�erSlgnature:(No S mps) MP/MPRSW No.: Business Phone Number:
as
Plumb r s A dress(Street,City,State, p Code): / n
IV. tiver
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps)
c Surcharge Fee) P
VApproved ❑ Owner Given Initial 4Jy 0(j �-
Advers Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD48398(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.
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.
SBD-6398(R.11/88)
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1)&Chapter 145.045)
LOCATION: SECTION: UNICIPALITY: ILOT NO.:BLK.NO.:j SUBDIVISION NAME:
tv �/$k)/ /T-?�N/RN E ( )
COUNTY: NE U ER'S AME: M LIN ADDRESS:
1
s�. Pau
USE DATES OBSERVATIONS MADE
NO. DRMS.: COMMER IAL DESCRIPTION: PR' I T NS:IPEBCOIATION STS:
Residence ew ❑Replace
RATING:S-Site suitable for system U-Site unsuitable for system
ONVE TIONAL: MOUND: IN-GROUND-PRESSURE:SYSTE -IN-FILL OLDING TANK:RECOMMENDED SYSTE%(optional) �'(��
®s ou Ms au �s ou a s Bu OS ®u com v. //ICG.',,jj]]''/////;
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.1-163.09(5)(b),indicate: —1 Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIG HES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BAC .)
-pp B I s J,60 � ' n S! 00 n e g
Alb > n S G r 9.6o R S
x.10 e (S 1 vvk 811 s 1 ?-00 n Med
B- a "J.`�� ��l,p � W B r /.7S A h fh to S
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B- �( `j !at�� 'b 7 9n G F h vt e s
is I.pO DrK Sn .pU 11 e
b o S
B- 1
PERCOLATION TESTS C�t�SS /$�C�3 sea
EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER WELLING INTERVAL-MIN. PERIOD PER19D 2 PER INCH
P_ S f- r0 IT
P- J q.a2z 0 10 /l' t'
P- als v
P-
P-
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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 .�
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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 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 pri9t : TESTS WEREAO P E ED QN:
/l a S 4n Q(►
ADD Ear CERTIFI TI N N MBER: PHONE NUMBER(optional):
CST I TUBE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER—
J
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•
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 k'tt' 1/ V 4t14115�
Location of property 1/4 '3&j 1/4, Section , T _N-R W .
Township
Mailing address ey
Address of site 0 y FIITI�;
Subdivision name
Lot number 'n
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable.? _ Yes No
Is this property being developed for resale (spec house)? Yes ��N0
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 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.
I
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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. dand corded in the Office of
the County Register of Deeds as Document No. ; 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 du
a ecorded in the Office
of the County Register of Deeds, as Document Ni ) .
Signat re of Owner Signa ure of Co-Owner (If Applicable)
/ IF9
Date Of Si nature Date o si nature
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ocktuoto
ROUTE/BOX NUMBER L 6 � �� �"e� � FIRE NO.
CITY/STATE ZIP
PROPERTY LOCATION: X1/9 �w 1/9, Section A , T °�� N, R1�W,
Town of /� , 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.
SIGNED
DATE �1 "
St. Croix County Zoning Office
St. Croix County Courthouse
911 9th Street
Hudson, WI 59016
(715) 386-4680
Sign, Date, and Return to above address
'DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR I/ .� SAFETY&BUILDINGS
OX 69 AN RELATIONS PRIVATE SEWAGE SYSTEMS PLUMBING
P.O. 9 BUREAU OF
MADISON,WI 53707
'SW, SW, 14, 28, 19W CONVENTIONAL 1:1 ALTERNATIVE (lState I nn I.D.Number:
Town of Troy 1:1 Holding Tank ❑ In Ground Pressure El Mound
Hwy 35
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Mark & C nthia Duenow 4605 River Rds . ,Afton,MN 5500
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: 77 T.ELEV.:
Name of Plumber: MP/MPRSW No.: County Sanitary Permit Number:
Thomas A. Wan 3231 St. Croix 128641
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.. VENT MATL:
171 GH WATER INUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑YES ❑NO ❑YES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF :PROPERTY WELL. BUILDING:JVENTTOF ESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORGE
M
the soil is dry enough to continue.) '41
CONVENTIONAL SYSTEM:
WIDTH: LENGTH. N DISTR.PIPE SPACING. COVER .INSIDE CIA.. #PITS: LIQUID
BED/TRENCH TRENCHES MATERIAL: PIT, DEPTH:
01MENSIONS
GRAVEL DEPTH FILL DEPTH IDIS TR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR N''.UMBER OF 'PROPERTY WELL: BUILDING:JVENTTOFRESH
BELOW PIPES ABOVE COVER. ELEV.INLET.ELEV.END. PIPES. FEET,FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ONO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
OYES ONO DYES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER. EDGES
❑YES ❑NO OYES ONO DYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
��t,yi�1IE1�tCH WIDTH: LENGTH LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOV
TRENCHES: E COVER.
. .�If1>•IN �NS i.
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
ELEV.: ELEV.: CIA.: ELEV.. PIPES.
.11EL VATI10N,AND
Tif4St 11 .I ION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
1l11FORMATION PLANS:
❑YES ❑NO DYES El NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER PRIOE ERTY WELL: BUILDING:
FEE T FFtom
DYES 1:1 NO DYES 1:1 NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE: _
DILHR SBD 6710(R.01/82)
Thomas C. Nelson son