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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER /-Q1,1J TOWNSHIP d SEC.�— T ,70N-R W
ADDRESS t- ST. CROIX COUNTY, WISCONSIN
2eqez�16-,la Yap Z
SUBDIVISION ,6/ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•I,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYW-M
D
9�(
�D
�S6
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
r
Elevation of vertical reference point. Pro osed slope at site: f /
P P
SEPTIC TANK: Manufacturer: iquid Capacity:
Number of rings used: _ Tank manhole cover elevation: f�, 9v�
Tank Inlet Elevation: I&OZ Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,V Rear, O �^ feet
From nearest property line Front
,O Side, . Rear,O feet
Number of feet from: well �C�f"�--' buildin
g: 19S
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
W �.
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: I X", Trench:
Width: / Length;_p� Number of Lines: Area Built:-./�/ �-
i
Fill depth to top of pipe:
Number of feet from nearest property line: Fro t, O Side, O Rear,0 Ft .
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: , Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one) .
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: '! �M- 1�7 Plumber on job:
License Number:
3/84:mj
J
�0
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON WI 53707 KR
CONVENTIONAL KRCONVENTIONAL ❑ALTERNATIVE (IarePlanI,D.Number
Town of Richmond ❑Holding Tank ❑In-Ground Pressure ❑Mound
Cty Road IS
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Rosemary Knutson 650 Monette Avenue New Richmond WI 54017 4.? S
BENCH MARK(Permanent reference Pomt)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PL ELEV..
Name of Plumber. MP/MPR SW No.. County: Sanitary Permit Number:
Calvin Powers Jr. 156 St. Croix 106053
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
_ PROVIDED. PROVIDED.
PO L') 0.0 I C7 I 1 C� Z� ®YES ONO OYES NO
BEDDING. VENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD: LINE RTV WELL. IBUILDING. VENT TO FRESH
ALARM. FEET FROM r—_D LINE AIR INLET
OYES ®NO OYES L�NO NEAREST `.V�
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNIN LAB ILOCKINGCOVER
PROVIDE PROVIDED:
OYES ONO ❑YE ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPE T IWEIL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST rev
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MA R L AN MARKIN;
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH. NO.OF DISTR.PIPE SPACING COVER INSIDE DIA OPITS LIQUID
BED/TRENCH TRENCHES MATERIAL: DEPTH
DIMENSIONS 1 ` '
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL. INOD ttR
OF PROPERTY WELL BUILDING VENT TO FRESBELOW PIPES ABOVE COVER ELEV INLET ELEV END. M LINE' AIR INLET
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.
OYES El NO
SOIL COVER ITEXTURE PERMANENT MARKERS 11111SIFIVATION W1 11S
1:1 YES El NO 1:1 YES ❑NO
DEPTH OVER TRENCH/BED D ED EPTH OVER TRENCH/B DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER. EDGES.
OYES 1-1 NO F-1 YES E]NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH-. LENGTH. NO.OF LATERAL SPACING 1GRAVELDIPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE M NO DISTR JD�s T R PIPE DISTRIBUTION PIPE MATEHIAL.&MARKING
ELEV.. ELEV.. DIA.. ELEV.. PIPES DA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS —1 LIFT CORRESPONDS TO APPROVED
❑YES El NO ❑YES ONO
COMMENTS: n PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF PROPERTY WELL: jB.ILDING
I�!— ))�� FEET FROM LINE
❑YES 1:1 NO 1:1 YES El NO NEAREST
I
Sketch System on Retain in county file for audit.
Reverse Side,
SIGNATU TITLE
Zoning Administrator
DILHR SBD 6710(R.01/82)
TI N
COUN
EZT,�IL.HR sANITARY PERMIT APPLICA O �.�--In accord with ILHR 83.05,Wis.Adm.Code
a� ""�«.�.� STATE SANITARY PERMIT#
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 9 NO
PROP RTY OWNER PROPERTY LOCATION
fl r1 a '/a, S Q-o2 T.30, N, R or)W
PROPERTY OWNER'S MAI NG A DRESS_ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
77 N
CITY,934TE IZIPCODE PHONE NUMBER Lj CITY NEAREST ROAD,LAKE OR LANDMARK
❑ VILLAGE: R)6h Olt
S& TOWN OR II. TYPE OF BUILD G OR USE SERVED: a PAC-
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify):
Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ® New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Y stem Se tic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a.X Conventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill . Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. X seepage Bed b. ❑seepage Trench c. ❑ See a e Pit
2.
PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
3 j,3 11.-55 11.2 k 1451.5 Feet DSPrivate ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank OCO /gam ❑ I El
Lift Pump Tank/Siphon Chamber _X4_,___ I ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Nam Print): Plu er's Signatur .(No tamps) IAVMPRSW No.: Business Phone Number:
Cgl��r a c„ ey,>-Tr.
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
IU
VIII. SOIL TEST INFORMATION
Certified Soil TesterMT)Name CST#
CST's ADDRESS(Street,City,State,Zip Code) � Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sffitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved F-1 Owner Given Initial 00 $urch Fiee
Adverse Determination
X. C MMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMITS
APPLICATION
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed .
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in #1. Complete#2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in #1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
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; dosing or pumping chambers; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes,was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground at+ar
included the creation of surcharges (fees) for a number of regulated practices which Wisco ih'S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure '. °
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
o
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources.These funds are used for monitoring ground- f
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
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 �0�(>t.P• %A So1-V
Location of Property W 1% Section T 30 N-R Iron W
Township _ 1?:1 C4*- l0 U
!tailing Address �p�,�� L�- , �p� 4j(p
VAcW V,t Cht A&O 1,4 D ` �!t s 40 k-I .
Address of Site _ GO
Subdivision Name
. Lot Number
Previous Owner of Property '(-tO ful ASS[L�
Total Size of Parcel
Date Parcel was Created P674&C A Eb 0&>
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for resale (spec house) ? Yes _k No
Volume $d 4 , and Page Number SO 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 1 o E the Re later of Deeds. In addi
Lion a
certified survey, v
R . y, if available, would be
helpful so as to avoid delays of the reviewing process.g p If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - -
PROPERTY OWNER CERTIFICATION
1 (loo I cow U 6y that of C A tdtemen,ts on thiJ► �olrm wce Jcue to the begs t 06 my (ow)
) .the
hncwtedgv_; that i (we) am (she owneh(,5 o6 the phopehty deAchi.bed in tit"
.in6olmaGion 6o&m, by viAtue 06 a wahh.anty deed neconded in the 066.ice 06 the
Coiin,ty RegiAteh o6 Deedaah Voeument No. 435o6-7 ; and that I (We) pneaent£y
C,un p4opoaed Aite 6oh the sewage dihpoa ayes em (on I (we) have obtained an
eahement, to nun with the above deAch,i.bed pnope/ ty, 601L the eon,&tAucti.on 06 aa.td
a ya.tem, and .the acne has been duty neconded to the 066tce o6 the County Regiateh o6
Cede, ae OocAmtnt No. 43 S o(0-(
SIGNATURE Olt OftkR SIGNATURE OF CO-OWNER (IF APPLICABLE)
-1-gr-th o
DATE SIGNED DATE SIGNED
i
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED f
43546'
REGISTER'S OFFICE
This Deed,made between James Thomas Leverty and ST. CROIX CO., WI
11i rgi n i a R T yerty , as husband and wife Recd for Record
;nine tenant
and Grantor, MAR
Rosemary K . Knutson , single person al 1:45 PM
Grantee, .• Register of Deeds
Witnesseth,That the said Grantor,for a valuable considerationk 3 S0.40
-__ RETURN TO
conveys to Grantee the following described real estate in St . C r o i x
County,State of Wisconsin:
Tax Parcel No:
Lot 1 Certified he Vol. 7fath9
Located in a f tNEa o eNWI of Section 22 , T30N, R18W,
Town of Richmond , St . Croix County , Wisconsin .
PMANSFES
$ o3
FEB
i
This- is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
-And
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
I -646eci 't-0 , fc:;efUcLY:o.,.; .�::! rr�tr rf ia�,:;. o-�
and will warrant and defend the same.
Dated this-------Z %l day of March 19 88
(SEAL) (SEAL)
• JAMES THOMAS LEVERTY
(SEAL)
(SEAL)
• _ Virginia R . Leverty
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
County.
authenticated this day of!__ St . Croix�,19 Personally came before me this ( day of
March , 19 8 8 the above named
James Thomas Leverty and Virginia
R . Leverty
TITLE:MEMBER STATE BAR OF WISCONSIN
(II not, to me known to be the person s who excuted the
authorized by§706.06,Wis.Slats.) foregoing instrument and acknowledge thasame.
THIS INSTRUMENT WAS DRAFTED BY ,.•'
t 1 L2
Jud. A Guise
Notary Public St . Croix nty�wvis
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (6f1hoC, sty ate a r t'ton
are not necessary.) date: November 10 .�w 8
'Names of persons signing in any capacity should be typed or printed below their signatures. NF 3573
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms,P.O.Box 10208,Green Bay,WI 54307-0208
FORM No.1-1982
H
• z
H
9
ST C - 105 r
9
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
9
OWNER/BUYER I_C)se V_;11 0 t-1
ROUTE/BOX NUMBER 'V0%A7'E 4 5X e)(0 Fire Number
CITY/STATE I41Fyy ( _IC44pAONC,�� W1 ZIP Gy' on
PROPERTY LOCATION : Kf,:: k, RVq k, Section T '�5'0 N , R NO W,
Town of P-AC-*A f aQC> St . Croix County ,
Subdivision , Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists of pumping out the septic tank every three years or sooner ,
if needed , by a licensed septic tank pumper. What you put into I[
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix . County residents may be eligible to receive a grant for
a maximum of 60% 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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping ( if nec-
essary) , 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 .
0
I/WE, the undersigned , have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
the standards set forth , herein , as set by the Wisconsin Depart- It
ment 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 .
SICNED �� � a 1i pq�
DATE �J�S4--ebeb
St . Croix County Zoning Office
P. O. Box 98
Hammond , WI 54015
715-796-2239 or 715-425-8363
Sign , date and return to above address .
U TMENT OF REPORT ON SOIL BORINGS AND SAFETY DINGS
INDUSTRY, cc T—vr�fISION
LABOR HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.090)&Chapter 145.045)
ILOCATION: SECTION: TOWN IP/ TY: LOT NO.:BLK. .: SUBDIVI ION NAME:
Ac '/ '/ /T N/R E (Or ¢.
WUNTY: 'S/BUYER'S N ME: r AILIN ADDRESS:
44L ],)-,r
i — a
USE DATES OBSERVATIONS MADE
®Residence NO.BEDRMS.: COMMER Cl L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
� New ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system ' ' 2Z :e
ONVENTIONAL:IMOUNC: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: ECOMMENDED STE :( ptional)
DS ❑U CIS ❑U CAS ❑U ❑S U ❑S ®U >
If Percolation Tests are NOT re uire DESIGN RATE:
Q 1 � If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:
.r PROFILE DESCRIPTIONS
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER IDEPTH 119. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BAC 1
•-
B-
B-
8 �.
B- ors
B- ? 3 s
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INOINIVS AFTERSWELLING INTERVAL-MIN. PER100 1 PERIOD PER PER INCH
P_ 1 ,r
P_ J 5 �
P-
P_
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil ar a . dicate scale or distances. Describe what are the hori
zontal and vertical elevation reference points and show their location on the lot-pfap. Show the ce elevation at pll b rings ndf�� �r�ction and percent
of land slope. ./ ' _ ,�/�� ��(�Lehr f 01�(.
SYSTEM ELEVATION la .� `� •�
X
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a
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1,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 WERE COMPLETED ON:
AD S : CERTIFICATION NUMBER: PHONE NUM ER(o tional):
zaz zl,)
P
CS GNATURE:
l
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) OVER —
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ROS e Ck r y yN c++v�
375100
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PAGE OF
r 1 0 r, o � A &f) S• step-�
Fresh Air Inlets And Observation Pipe
1 Approved Vent Cap
Minimum 12"Above
Final Grade
20-42"Above Pipe —4"Cast Iron
To Final Grade Vent Pips
Marsh Hoy Or Synthetic Covering
O ur Pips
win 2"Aggregate
Dlaulbatl - —Tee
PIP. -� 0 0 0 0 0
Be Aggregate Pipe o Perforated Pipe Belo.
Beneath Pipe
o —Coupling Terminating At
9ollom Of System
Paup ['�
o nl c D T i n�-'
L .,j
SOIL FILL
DISTRIBUTIOF.1 PIPE
APP R.OVEO SIIpITNETIC COVER
Z"OFA6GREWE —�r r r o a OR M RISK MA,-J OF STRAW
(o,OF AGGREGATE
ELEV. 0F1Q1.5FEF-T—.-
DISTR1RtUTIc0M PIPE TO BE AT LEAST �� INCHES BELOW ORIGIAJAL GRADE
A►)V AT LEAST20 INCHES BUT AIO MORE THAI) 42 IMCHES BELOW FINAL GRADE
MAXIMUM WN OF EXCAVATIOWI FROM ORIMNAL 6RAdF. WILL BE 4.'41 IUCHES
MIKIMUM gr-f" OF EX WATIOM FROIA a�141WNL. (3RApF- WILL BE —26-_ INCHES
SIGHED:
LICEUSE
i
DATE :
110 J