HomeMy WebLinkAbout020-1152-40-000 z .
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AS BUILT SANITARY SYSTEM REPORT
OWNER T n7 q
", ► TOWNSHIP ART aWr,04,�; SEC.,G3To�IN-R
ADDRESS `-
✓� lu "r a^ ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION_ j aoy LOT
a� LOT SIZE 9 S!J x
PLAN VIEW
Distances and dimensions to meet requirements of H63
' ERYTHING WITHIN 100 FEET OF SYST
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I di a e o th Arrow
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BENCHMARK: 't-JEL
(Permanent reference Point) Describe: Tom �� tau n T
Elevation of vertical reference point : /✓® o
Slope at site : I
SEPTIC TANK: Manufacturer:
Number of rings on cover Liquid Capacity':
._--_� Tank Inlet Elevation: Tan manhole cover elevation:' y ZV** -
d Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: '--. Number of gallons
Number of .gal . pump set or a cyc e gallons ; capacity o
distribution lines
. .,s p�`,, al _, gallon: size o pump tota
, -� g lon per minute horsepower head;
and model number p ran name of pump
Type of warning evice ,
HOLDING TANK: Manufacturer
Elevation of manhole cover Number of gallons
Ty e of warning device
SEEPAGE PIT SIZE:
feet liquid depth um er o pits eet
bottom of seepage p ameter
seepage pit in e't-pipe-elevation -`
it e evaton
SEEPAGE BED SIZE: number of lines feet .
SEEPAGE TRENCH: width wi th_1� ��le,tigth .3'( tile depCEt �Tof
PERCOLATION RATE / r+� �' A REQUIRE-4 l S"
RE B --
DA'Z'ED_ INSPECTOR tuY�-
PLUMBER Off-j-0-B-1 �Y
LICENSE NUMBER.___ :
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KLPOKT OF 1NSPECTIQN -- INUIVIOUAL SIWAGL SVSIIM
Sani 1ah11 Vvtirn.( 1 —
t Stale SVp4`4_e/4(� '
Cpl/'
Towns h i.r� s t. C, o4' x Coun.r�:
SE Sectio Lot M tiu.bdivi,6 i.o
rl W 1ANK
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gall0MIA" Numbers o6 cornpahxmenfia
Highwa.te4
,rtvIV1N(1 CHAMBER I� E
�a.tt9nd _. ,f µ)+p Man a:ctuneA. _ Model. Numbe.h_
f,l I 1)/ N.(; TANK
'`de/t 06 Carnpanfimen.te
('urril,eh siAOAM Syetem —
, .� Lunt'(? 640M1 We4t ' " _ 12% al.ope
N.ighwa.teK � -
I ION SITE
I ,16cc 6,loms We.�?_ -_. -- building 12% slope
114.ghwa.te n
Ob-1' 1 ION SITE DIMENSIONS
10 , dth o6 •ta.ench 6t Re.qu.i.hed anea /
1 ,'n(Ith o6 each tint z �' �t Depth o6 nock below the to
4------
Numbe,q o6 linee. _ Dep#h. o6 )Loch oveh tile*
►otal length 06 ti.ne,e6.t Depth o6 •ti.le, below gnade.�_ i.n
04 a Lance between, tine6 6,t t 140pe. 0, 6 .tKench-- n . pen 100 6t
i i, toe abe onption aaea .6.t Type o6 CoveA. ape�c n e thaw
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(3x0v hound pcta yea n(
oll IN 411v di.ame:te.n r t.� ''�Dept:I below 4"ne -t
to I' abAonp.tion a4ea t
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DATE 19 8
_._-------
DATE - ------ 191'1
I Al:()N I ON Ill:JECTION
7 6
State and County State Permit #
PLB 6 7 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:
T f T lL,a i a c zo u AJ
Al 47— C,�t itie , r �it T Y 441/
B. LOCATIO : 61.1 % Z '/4, Section,_, T,;�J N, RIT 411111 (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk#ff)fAeL-,t &tWJ Village
Township 9sT
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X— Duplex No. of Bedrooms .� No. of Persons
D. SEPTIC TANK CAPACITY f''0 4 ,6 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete_X 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 )e Replacement Alternate (Specify)
Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches
Seepage Bed: A Length X6 t Width Z-0 f Depth4-" Tile depth (top) Xc& • No.of Lines
Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits
Percent slope of land— h 7. Distance from critical slope
WATER SUPPLY: Private 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 H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME Jr-7-15-414 it C.S.T. # 'ela -6 and other information
obtained from (owner/builder). /
Plumber's Signature MP/MPRSW# Phone
Plumber's Address fal T e, `L t-1Z ed" Q.A
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''��R COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application C_�_UL_Fees P id: State AK, y ° �� ate
Permit Issued/Rejected (date) Issuing Agent Name
Inspection Yes No State Valid# Date Recd
1. county (while 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
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:-�W%-5k%,Section,`t,TON, R/III (or).W Township or Municipality ."N 41/s-A
Lot No. Block No. Fax y A C C ,c Y _County r fr-V! x
Subdivi on Name
Owner's Name: 6;;!/! At-Z C "''' `�
Mailing Address: 4-07- T a
TYPE OF OCCUPANCY: Residence x No.of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW x ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS 4-1`a
SOIL MAP SHEET SOIL TYPE -e X � •� T�' RKti, 11,d r
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
sx" Ale. Sol
Alo
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)
A `° r•S.L. �/`' ��!
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate gumber of square feet of absorption area
needed for building type and occupancy. 6' 129'In 1" T Xxe- Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) �T .d� � I'70'6:;e Certification No. 6
Address T
Name of installer if known '.y'l�F, p� 4.
COPY A—LOCAL AUTHORITY CST Signature
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