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HomeMy WebLinkAbout020-1025-30-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 212 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Gillenwaters, Dennis Hudson, Town of 020-1025-30-000 CST le Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: 15.29.19.110A2 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt.BM Aeration Bldg.Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist.Pipe Holding Bot.System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist.to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM I i — Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia I Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedlrrench Center Bed/Trench Edges Topsoil ® Yes ❑ No 0 Yes ® No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Ins1ion#2: Location: 962 Bakken Rd Hudson,WI 5401(6(SE 1/4 N10 /4 15 T29N R1 ) NA Lot 2 \� \O � arcel No: 1\`29.19 110Pt2 1.)Alt BM Description \v 2.)Bldg sewer length -amount of coveVT$1'WAQq1t Plan revision Required? ❑ Yes F N o l F-1J Use other side for additional information. I Cert.No. Date Insepctor's Signature SBD-6710(R.3/97) P 1�� IUY ,--. ell ell",r�l 17 County 5'9Ytftarp Peralnit Application ST.CROIX COUNTY WISCONSIN In accord with Chapert 12 St.Croix County Sanitary Ordinance PLANNING&ZONING DEPARTMENT "d T Personal information you provide may be used for secondary purposes ST.CROIX COUNTY GOVERNMENT CENTER [Privacy Law.S.15.04(1)(m)) 1101 Carmichael Road Hudson,WI 54016-7710 L (715)386-4680 Fax(715)386-4686 Attach complete plans for th.e system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit# ❑ Check if revision to previous application 2-17 I. Application Information-Please Print all Information Location: 11property Owner Name 1/4 0*�114,Sec -2 c7 N, )f.0 R j a E(ora Property Owner's Mailing Address Lot Nu Block Number ,?,:!�;,z '9 "A City,State Zip Code Phone Numer Subdivision Name or CSIJ Number --/6 e,4 5-C)"i Z4.-1 /)ei / / ;,z I '? 11 Type of Building: (check one) Mity 0VIIIage KTown of 1 or 2 Family Dwelling-No.of Bedroom f1 Sty Public/Commercial(describe use): State-owned Nearest Road Property Location: 1City,S S 147 1p, 11 Ty 10'r, spi 11.Type of Permit: (Check only one box on 11ne A. Check box on line B if applicable) I Y Parcel Tax Number(s) A) 11.)q Repair ❑ Reconnection 3.❑Non-plumbing 4,❑Rejuvenation 16 -4— 'A B)f---- V I Sanitation Permit Number L,, Date Issue 411- 1, _I ❑ State Sanitary Permit was previously Issued 7Z �4e) .7 IV,Type of POWT System: (Check all that apply) f A Non-pressurized In-ground ❑ Mound a 24 in.suitable soil ❑ Mound:5 24 in.suitable soil ❑ Mound A+O ❑ Sand Filter------ ❑ Constructed Weiland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V.Dispersal/Treatment Area Information: 1. Design Flow(gpd) 2. Dispersal Area 3.Dispersal Area 4.Soil Application Rate S.Percolation Rate 16.System Elevation 7. Final Grade � �_Cy Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation VI. Tank Information Capaicty in Gallons Total #of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks Q i e5f- & ❑ ❑ ❑ ❑ ❑ ❑ VII.Responsibility Statement 1,the undersigned,assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POVVTS shown on the attached plans. A license is not required for terralift repair or the_installation of non-plumbing sanitation system. lumber's Name(print) Plumber's Signature(no stam s): MPRS No. JBusiness Phone Number ... r 4 Ad-h' 6,,L gake_i- 1 -1 Plumber's Address(Street,City,State,Zip Code) Vill.Count se Only Disa r d Sanitary Permit Fee Date Issued Issuing ent Sign ure stamp ><Approved Owner Given ial Zzs OCR 2Z on 33 X Conditions of Approval/Reasons for Disapproval: ►� plt,w. . ����- f L3 II-f t/� �`-� t �G e lee' 7-e- C4 lic f" /t/,'S T i l Al 5:4,4 aw i/.,Ize,, aA.--i ro 171.t POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner e .j � 67;/le N dT e t5, Septic Tank Capacity gal ❑ NA Permit # Septic Tank Manufacturer ? ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer /:-4 ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) gallday Pump Manufacturer ❑ NA Soil Application Rate al/da /ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cells) ❑ NA Biochemical Oxygen Demand (BODE} 530 mg/L ❑ In-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y.in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank ❑ month(s) (Maximum 3 years) 13 NA At least once every: ❑ ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA ❑month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) A4 least once every: ❑year(s) ❑month(s) A Clean effluent filter At least once every: ❑year(s) ❑month(s) ❑ NA Inspect pump, pump controls& alarm At least once every: ❑year(s) ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑yearls) ❑ month(s) Other: At least once every: ❑ year(s) E3 NA Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. • START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/air damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins;tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the rec'scement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ T site d site e tank ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name �.' f f Name Phone 7 j 5„ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name 4-. �!"D Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f)and 83.54(l), 121 &(3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT �--� AND OWNERSHIP CERTIFICATION FORM OwnerBuyer_ I I e tiny" �;���e,rJ e v eYc Mailing Address Property Address (Verification required from Planning&Zoning Department for new construction.) City/State Fy4_1_e4 ev,` � alG Parcel Identification Number—O;R.0-�.�p?5- 3 0..,,�-e3 o p LEGAL DESCRIPTION Property Location l^ '/4 , IV L::� %a , Sec. 16' , T_11_N R. V W, Town of Subdivision Certilled Survey Map# fje/ / , !Volume � , Page#. 9./ 7 �. Warranty Deed # __. __ , Volume ­ _. Page#_ Spec house yes Lot lines identifiable ye no SYSTEM MAINTENANCE AN OWNER C'ERTI +,,ICA'TION 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 pumper. What you put into the system can affect the function of the septic tang as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in SComm. 83.52(1.)and in Chapter 12-St.Croix County Sanitary Ordinance. 'The property owner agrees to submit to St. Croix County Planning&Zoning Department 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/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set#arth,herein,as set by the Department of Commerce and the Department of Natural Resources,State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St.Croix County Planning& ;Zoning Department within 30 days of the three year expiration date, Vwe certify that all statements on dos form are trice to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above, by virtue of a w anty deed recorded in Register of Deeds Office. Number of bedrooms 3 /V- SIGNATURE X �!�as L/r OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary Permit being revoked by the Planning&Zoning Department. *** Include with this application a recorded warranty deed front the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.08105) 331503 r r 331503 D ' CERTIFIED SURVEY MAP Located' in the SE J of the NE of Sec. 15, T 29 N, R 19 W. Town of Hudson, St. Croix County, Wisconsin -_ To wrn Rogd _ ._---- - -- - - - - -- ¢- -- - ----- - - - -—�-- - S.E.1/yofN.E. %4 AIM; Sec. 16'-29-19 CERTIFICATION: I hereby certify that I have surveyed and divided the lands shown hereon; that the 0 S- /6 A map and description shown hereon are true 1 and correct representations of the lands h Z T Road lI I as surveyed; and that I have complied with Egse-knen all the provisions of Chap. 236.34 of the 2 S5 ►o Wisconsin Statutues and the subdivision regulations Of St. Croix County in sur- ' AlGo.zo ° veying, dividing and mapping said lands. soles �e�o �1, Survey for Art Bakken ' 0 amft R f G u p S. 09 A. N�� ,fit egf ste*&': nc prveyor •f�oad Easer,�Qr/f 1 Dated. Jq''2Q,�i�7b .2 'r`'`e•so o �•• Y cA • , j i �� X80•iO+RS'w A S 89.30-e 1p°S9 ��i�s/i' �,2G.3o - Indicafes iron pipe 6� s•fgkt 24"/on9 , Z -33'Rogd Egse►•r�t/ii o /� �� /'digrn. Lof 3 �i•: o Lod 27A. ti,y�/ S. 0z A. 1� Sic. Line 33 'Roud E45erje ref � 'e•s•d , � � a •�� o° .2� • pf o-F be ginning: i`' 914grf�►- cornet- 39T G3 N,? SGB.�o r of Sec. /S, T29NR19W /V B9°39'W 966. 03 - '� DESCRIPTION: That certain parcel of land or tract of real estate located in the southeast quarter of the northeast quarter of Section 15, T 29 No R 19 W, Town of Hudson, St. Croix County, Wisconsin further described as gollows: BEGINNING at the east quarter corner of said Sec. 15; thence N89 391 W a distance og 966.03 feet; thence N 10 07' E a distance of 867.66 feet; thence N 1 59' E a distance of 460.09 feet to th2 north line of said quarter-quarter; thence with said north line S 89v 060 E • distance of 484.50 feet; thence along the centerline of a road S000 541W • distance of 455.80 feet; thence S 13v 36' E a distance of 371.57 feet; thence S 2280 ;61 W a distance of 98.00 feet; thence leaving said center- line S 89 30 E a distance of 426.30 feet to the east line of said Sec. 15; thence with said section line S 10 33' W a distance of 418.75 feet to point of beginning. V o 1.,_ l,rte Page 217 Certified Survey Maps St. Croix County, Wisconsin \ \ j C, \ [ 2 � � E) ƒ 2 ; L ƒ 2t ] a % $ oa k ƒ§CA\a � , o LL .2 fro 3 ) d) < a co n \ W E 2 ., o \ w IL c F- m k § / ? ¥ E � N m § \ { I c . § A ƒ 3 / § $ § .2 / / Q k ) k \ ) k � .. � � E k .. � � � £ (D2 $ ] � ° o o a ƒ / ) � k _ .. \ § § § -� 9 _ a IL a CL Z U © o 2 v § G \ 2 - - © © I c a m 3 3 G G 3 7 § § f g I @ zz » § Q \ $ $ < ) 2 § ® q § < ) - -$ E co LO I- F- co co m § \ § § M / \ \ \ § § § § o � _6 - c = - c & _ e = a a a - 2 ) 7 / k 3 § / 5 5 \ CI = g a t \ p 2 2 D f 4 / 2 k •• ate e o / ) k co) 0 '.ER , TOIJNSHIP SEC. T N, R�W 0. ADDRESS , ST. CROIX COUNTY, WISCONSIN. `3DI�I ION LOT LOT SIZE PLAN VIEW f -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING 47ITHIN 100 E OF SYSTEM `TIC TANK(S) MFGR. CONCRETE EEL N'0. of rings on cover Depth DRY WELL INCHES NO. of width length are no. of lines width length= area depth to top of pipe 3REGATE -K RATF,4 , AREA REQUIRED_ AREA'AS BUILT ,claimer: The inspection of this system by St. Croix County does not imply complete % , .pliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for � '_tem operation. However, if failure is noted the County will make every effort to (.;ermine cause of failure. 'BASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM, INSPECTOR � � // / DATED_ PLU2•1BER ON JOB LICENSE NUMBER G MPORT OF VISPECTI011--INDIVIDUAL SEWAGE DISPOSAI, SYSTEM Sanitary Perm,i�%�� ., ). l State Septic TOWNSHIP • t. C oi.� County 5F"TIC 7A'11, Size / Q gallons. 'Dumber of Compartments Distance From: Tell t. 12% or greater slope ft Building ` ft. Wetlands f: Iiighwater — ft. DISPOSAL SYSMH Tile Field or Seepage Pit(s) Distance From: hell , 12% .or greater slope ft Building; _ft. Wetlands f 7. FIP•.LD Kip' water ft. Total length of lines -3 ft. Humber of lines 3 Length of each line 3 ?_£t, Distance between lines ft. Width of the trench ArT ft. Total absorption area sq. ft. Depth' of rock below tile _Z e–in. Dp-pth of rock over tile _in.. Cover = t. _ -over.rock., Depth of tide below grade in. Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to .round water £t. PITS Number of pits �. Outside diameter ft. Depth below inlet ft. Gravel around pit : yes no, .Total absorption area sq. f t . Square feet of seepage trench bottom area required • Square feet of seepage nit area required Inspected By: Title':. Approved Date 197`. Rejected Date 197 3 ��o . PLB67State and County State Permit Permit Application County Per 't # ® for Private Domestic Sewage Systems Count ` *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWN OF PROPERTY Mailing Address: i1 B. L CATION: '4 Section jib, T N, R E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPr OF OCCUPANCY. Commercial *Industrial *Other (specify) *Variance Single family _��Duplex No. of Bedrooms No. of Persons_ D. TYPE OF APPLIANCES: Dishwasher YES O Food Waste Grinder_YES 4110- # of Bathrooms Automatic Washer ;�(�ES NO Other (specify) E. SEPTIC TANK CAPACITY f n® Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation L-- Addition_ Replacement_ Prefab Concrete *Poured in Place Steel Other ecify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate tal 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 i Tile Depth r No. of Lines Seepage Pit: Inside diameter�,�--Liquid Depth Tile Size Percent slope of land_ f /[�_ Distance from critical slope 1, 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 oil a er, NAME –t C.S.T. # nd other information obtained from (owner/builder). Plumber's Signature 4fP1 1:�A�MP/MPRSW* W1,Z- _Phone Plumber's Address Tom' PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). 4 /olef'14> Do Not Write in Space low/- FOR DEPARTMENT USE&NLY 0 Date of Application Fees Paid: State 8 Co nt �� ate 7 Permit Issued/Rejected (date) _Issuing Agent Name Inspection Yes_4_No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 16—2. state (pink copy) 4. plumber (canary copy) Revised Date 6/11/76 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 TESTS LOCATION: '/4, �/,,Section rSTAN, R_NE (or) W,,Township or Municipality Lot No. —9—, Block No. �('� /t/ " County ©�� EN i S�b , sion Name an be— Owner's Name: Mailing Address: 0 1 P_L — TYPE OF OCCUPANCY: Residence No.of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET SOIL TYPE r/ KKlaT 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 BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P—/ P-� )�S P_3 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) *> ­7' ff A)n Al is 7 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square fee of suitable eas. ndicate number of square feet of absorption area needed for building type and occupancy. G F-O Indicate scale or distances. Give horizontal and vertical reference poi t Indicate slope. t TN , $s ALZRAlff r / 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) No. Address LL ul Name of installer if known ># CST Signature COPY A—LOCAL AUTHORITY