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Home My WebLink About036-1082-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St, Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 5582027 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)]. Parcel Tax No: Permit Holder's Name: City Village Township 036-1082-50-000 Debra Frey TOWN OF STANTON Sectionrrown/Range/Map No: CST BM Elev: Insp. BM Elev: BM Description: 32.31. 17.5510A /t7 ~l ~'e,C' Go ~rw TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ll CAPACITY STATION BS HI FS ELEV. 7 Benchmark J~3 r7 Septic -r^ " 3. LJ A- Alt. B rl p ! 5 .'t~e,~ Gay Aeration Bldg. Sewer x; b Holding St/Ht Inlet G ,`7 q7• 63 St/Ht Outlet 7,6 411o.7 TANK SETBACK INFORMATION TANK TO P ~ WELL BLDG. Vent to Air Intake ROAD Dt Inlet 1 Septic I Dt Bottom 1 ~.4 AA6 Dosing Header/Man. Dist. Pipe Aeration Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Demand St cover Manufacturer 9~ `7 GPM CIA J / Model Number TDH Lift ion Loss System Head T Ft Forcemain th D' Dist. to well SOIL ABSORPTION SYSTEM PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth BEDITRENCH Width LNo. OfTrenches DIMENSIONS SETBACK SYSTEM TO L LDG WELL LAKE/STREAM CHLEACHING AMBER OR Manufacturer: INFORMATION Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Al Vent to Air Intake Header/Manifold Distribution x Hole Size x Hole Spacing Pipe(s) Length Dia Length Dia Spacing SOIL COVER x pressure Systems Only xx Mound Or At-Grade Systems Only xx Mulched Depth Over Depth Over xx Depth of xx Seeded/Sodded Bed/Trench Center Bed/Trench Edges Topsoil Yes ~ No ~ Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) inspection #1: Inspection #2: Location. 1556 CTY RD K ts~ ~it. a 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover = Plan revision Required? 0 Yes 'No Use other side for additional information. Date Insep rs Sign a Cert. No. SBD-6710 (R.3/97) RECEIVED County PIK r, 1 Zo Safety and Buildings ion GO X ,OCT 4 ` D S 201 W. Washington Ave., P. 62 tary Permit Number (to be filled in by Co.) S. CROIX COUNTY Madison, WI 537 -7162 , UNITY DEVELOPMENT State Transaction Number Sanitary Permit Application NN In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing add ess) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 11 to I purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. S 1. Application Information - Pleas t All Information C Property Owner's Name Parcel # Property Owner's Mailing Address Property Location d 0 ~ ~,51b Govt. Lot _ City, State ZPhone Number W / y,, Section 3 /w z C AmO~/~ / w` cucle one }I T -S I N; R E or W II. Type of Building (check all that apply) Lot # 3 Subdivision Name ~at,l or 2 Family Dwelling - Number of Bedrooms Block # ❑ Public/Commercial - Describe Use ❑ City of CSM Number ❑ Village of ❑ State Owned -Describe Use /~JI ownofQt/l. I - e. / III. Type of Permit: (Check ly one box on line A. Complete line B if applicable) p A. ❑ New System ❑ Replacement System Wfreatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued ermit Transfer to New B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber FOwneT Before Expiration IV. Type of POWTS Sys . tem/Comonent/Device: Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: De ign Flow (gpo) Design Soil plication Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation v K§ 44 ^q VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U ,yC U U ~ y y N New Tanks Existing Tanks o 0 n n i V C% Septic or Holding Tank 10 Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signa MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) / VIII. Coun /De artment Use OnIv 17 Permit Fee Date Issued Issuing A Signature Approved ❑ Disapproved $ rven Reason for Denial 0 ` A / IX. Condi asons for Disapproval OIL, 't GD 1, S ptielank, efHui> pflter and 3 utri w .dispersal cell must all be services I 'ma ntainecf 1 l 1 ~l ~l f` . as per management plan provided by plumber. I A4M I-' A- lne.JJ 2. '*&vlllp, E#c c requirement; must t r►taintained } r as per appkable code / ordinances. 1 . Attach to complete plans for the system and submit to the County only on paper not less than S t/ x 11 in es n size SBD-6398 (R. 11/1I) AS BUILT SANITARY SYSTEM REPORT ;ER , TOWNSHIP,S,&rat) SEC.. T-3/N, R_ 2w ADDRESS , ST. CROIX COUNTY, WISCONSIN. 3DIVISION LOT LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f ! I i _4_ t i I I i ~ } ! 1 1 ( ~ I Iz I I 1 I M I G ( j I I I I I I ~ i ~ I ! I ! 1 ~ i r i j j i -l j j f TIC TANK(S) MFGR. COt,C. I ndticae Noich Ah~ ow 7 ~n c ( tea, c Xr U1 TE~ STEEL S cat e Nb. of rings on cover Depth + DRY WELL :'vCHES NO. of - width length area no. of lines width / length area dept to top of pipe CATE RATE ~ ` ,L° 1C• - ri AREA REQUIRED j~ AREA AS BUILT C)~ claimer: The inspection of this system by St. Croix County does not imply complete Dliance 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 eresne cause of failure. ti.SES ILND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTM. --INSPECTOR DATED -72 PLUMBER ON JOB_~ LICENSE IT UMBER a"-0Id"" 31U 9St~8-5Z~-008 0 OSL~S M '>130H N301VW OL "H sn 9LL£M z \ r- anod-lsod 31V0 00 00 00 31v0 ivnN` V4 OI1d3S w o =anod-3ad .o-,L="ti L 31vos dOM l8 NMV2l0 31313 goo V3531M 8w-000tdlM N D w w H Q z k a v co O LAJ w o p x Ir D N cn m w W to a Z °o ~ o JJ °W U5 m w d Un W F J J F J of LA Q w ^ F > w o Om °1kQ z a w~ a Z o o z < HO W Of 0- a. 0 ce 15 HW 0 Z 0 f5 U Q a o~ U aW ° fN mVI ON M U} O \ w a a- in Ci -j in ct O LL- M N tO m W a Q Lt1-j p Q z o z a a O U = UOpdMO N~ mNF N WWQ OD - co 05 ImIrlh F<- O w C-4 a. N~* °W~WWJW0) W<< W < Ja WO ZZ Y T- \N = gOe J>W I U ZN =U Z ~C9 Zp N ~O~-cOOZJH O<w °°W Q Z►-Q In WU pw° I-= Y Z:~ ~!z2o0°~2 °vviF- o< ° zW xx wv °<o o<Ww°Wa' aa ~ ado U c~oQ z <V) 2~ o z Z3m U2 xJ~m~w3 ~ ° z o ow Q W W W 5 9 < Y Z Z _ OJ WZ N V~ U J W (n 1 ~ W 0 ~ "6F o W O a W D D W P' N O U- N m _ < o <1 5 ° .92 w l~ ~I. o W 0o J O H ° ~ N W W J Z_ U < U - D Z < "98 2 038lf1b321 St/ „£5 ww < N Y z < H ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM l Owner/Buyer I;Izx Ake y Mailing Address Property Address /.~.Sli / , ,I/~w ~Z~~.a. ~Z XV1017 (Verification required from Planning & Zoning Department for new construction.) City/State Ac,-&, 9'r-4- Parcel Identification Number 6.76 - /0 8Z - S0 -vyy LEGAL DESCRIPTION Property Location 1/4 , r Sec. 3 Z , T 3 / NR /2 W, Town of 7• H Subdivision Plat: Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ❑ yes kno Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(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 forth, herein, as set by the Department of Safety And Professional Services 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedroo s 19"11 1/1 o/ I~LY SI ATURE OF AP 12- / T( DATE ATE ***Any information that is misrepresent ay r It in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warran deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) O O O O p t» v O 0 C h O O ~ L C N m N 0 0).- E (D Q v nnu) O CO _ N ~ N 0 co ,y I N t U ~ h N H~3 I `i ~ O 'd Z 3 c0 ~ O 000 (0 N yLQ U. O O E C m O Q n _ a) (h w E cn = o Z v ! M lj1 Z ~ N 1, J ~ J Ni i H c~) a c') N z < 3 oz c N O O Q 1 ~Y C N _\V\I y N r N "INA 0 (D z ca z Icy- 0 La m n y a 'T N d N ` t~ 3 ►y- 3 0 9 (D c 0 0 0 a d M •P 0 n. a a CL t% J U rn rn Z N r .O LO O Cl) Y N M _ O O O O N N N ` 0 0 7 °O = N 7 L N o °y aNi rn (D ^ D O O y N U ty' w y C .r ° O LO o E J U ° _ o a) va°ooool L~p f i r H H U) N a° N , m N M (D r N C o M 0 N Z c Q:1 Q Q Z: ) o n u c o a~ o f L G~ LO . O M fn U U Z II u a E 2 .2 o °.3 c Parcel 036-1082-50-000 09/19/2006 04:16 PM PAGE 1 OF 1 Alt. Parcel 32.31.17.510A 036 - TOWN OF STANTON Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - FREY, DEBRA K DEBRA K FREY 1556 CTY RD K NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1556 CTY RD K SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 14.480 Plat: N/A-NOT AVAILABLE SEC 32 T31 N R1 7W 14.48 AC W 478' OF SW Block/Condo Bldg: SE Tract(s): (Sec-Twn-Rng 401/4 1601/4) 32-31 N-1 7W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1186/512 QC 07/23/1997 838/94 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/06/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.480 15,000 146,900 161,900 NO AGRICULTURAL G4 13.000 1,500 0 1,500 NO Totals for 2006: General Property 14.480 16,500 146,900 163,400 Woodland 0.000 0 0 Totals for 2005: General Property 14.480 16,500 146,900 163,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 207 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 • AS BUILT SANITARY SYSTEM REPORT .."R A) , TOS•TNSHZP 32 T ' j, ADDRESS _ ST. CROIX COUNTY, WISCONSIN. ~ N, R_~W 3~JZVZSIOa~1 LOT LOT SIZE ' PLAN VIEW -Distances dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i ~ I ! i I ( I I I I i i I I I i I ;'TIC TANK(S)_.~L~_ MFGR. COP~CRETE STEEL Indicate Nanth Ahnaw NO. of rings on cover Seale tiCHES NO. of Depth r~ DRY WELL width length area no. of line~tt width / length area dtop of pipe 37 LATE RATE AREA REQUIRED AREA AS BUILT Jaimer: The inspection of this system by St. Croix County does not imply complete •_,aliance 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 stem operation. However, if failure is noted the County will make every effort to _~erz~ine cause of failure. '-ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTE2 `INSPECTOR DATED( - Z,G._ PLU:IBER ON JOB 1~ A" LICENSE NUMBER r t REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM Z • ' _ _ San.i,tany Pehm.i-t~ ` State Septic NAME ` - Fownbhi St. Cfco 'x County p .c Locat.iog CzJ SF Section SEPTIC TANK i S-i.ze_/&VI gattonz. Number o6 Compantmentz j Distance Fnom: Wett St. 12% on greaten sZope 6t Bu.itd.ing~6t. Wettand.6 . ~ . H.ighwaten DISPOSAL SYSTEM Distance F,%om: WeZ 6t. 12% on greaten sZope it. Bu.itding _Sx. Wettandd Ft. H.ighwateA FIELD DIMENSIONS: Z Width o5 znench /l 6t. Depth of rack below tite-L4--in. joblo- Length e6 each Zane_st. Depth a6 rock oven t.ite IL .in. Numbers o6 tines Z Depth o6 t.ite below grade I-e:- in. Totat .length a6 Zinez J $ 6t. SZope a6 .trench in pen 100 6t. Distance between tinea G ,t. Depth to bednoeh 6t. Totat ab.bonbtion a&ea-n# jt2 Depth to gn-ou.ndwaten g . _ Requ-ined area ~t2 Type o6 Coven: ape on Straw PIT DIMENSIONS: Numb en o6 pits GAaveZ around p.itzs yeas no Outside d.i.ameten Depth below .inQet 6t. Totat abzoAbtio a 6x2. Area nequined 6 t2 m INSPECTED BY TITLE APPROVED DATE 197. REJECTED ,DATE 197_„ EH 115 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES " P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION;, Section.3Q_,TJ.N,RJ_Zj (or) Township or Municipality N5.ZAA12ZglJ Lot No. , Block No. Subdivision Name County sT• CZk" Owner's/Buyers Name:: S& ZZA O.A Sd tJ Mailing Address: ~n A&Au jdc.,~ ",(~j~/ TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW~REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 6-Q1_ ?q PERCOLATION pTESTS 71:21- SOIL MAP SHEET QD NAME OF SOIL MAP UNIT d6&kAlT -S/)T1XA e,2mp/ 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 P- I P- 1 i #I / f:f P I~ , P P_ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B 7 - B- B- _ B- U - Z2 7 S-o Z2 S-4 B- - 669-40.,4, 40 _ r' -91e, 10- YdT-A.!2 B- 7 a PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan thq loza ion and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy,Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. /00 S& him I • t_ I . b// E 01 1 / s el N E '7 : E ~ s E E rf V I-N s F l 01. I, the undersigend, hereby certify that the soil tests reported on this form were made by me in accoM 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) Certification No. Address Name of installer if known Copy A -Local Authority CST Signature I. PL9".67 State and County State Permit Permit Application County Per it # for Private Domestic Sewage Systems County , 0/44-4- *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: r1o x -1 Jh _r sue? > B. LOCATION: Akj %.&C, _Y4, Section, T_,34 N, R,a I (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township S?i'9J/JW C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons_ D. SEPTIC TANK CAPACITY Jf 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. EFFLUENj DISPOSAL SYSTEM: Percolation Ratey~fotal Absorb Area sq. ft. New J( Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: -p-Length SO/_Width oQ Depth :~O Tile depth (top) t No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope 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 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 A111 ke C.S.T. # and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW# Phone SS-1 ,3- lc~ 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. i r ? a 3 3 r E O , i j-.1 t__ ~a _ ryc 1: u , u e E ca Do Not Write in Spa elow. OR COUNTY AND STATE DEPARTMENT USE NLY Date of Application Fees Paid: State? oo unt ~ Date 9/9,5 Permit Issue' (date) Issuing Agent Name Inspection YesX-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 EH 115 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 r, V LOCATION: f(' /4,SL %a, Section-3,X T N,RZ~ or) W, Township or Municipality County Lot No. , Block No. Gro IX u rvlsion ame r Owner's/Buyers Name:--7_O,4 Mailing Address: «r S C TYPE OF OCCUPANCY: Residence-No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 141 - 2 2. PERCOLATION TESTS SOIL MAP SHEET 9C> NAME OF SOIL MAP UNIT - -S 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 AFTE INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- f - d o 5~ 8 P- L ?r file Z P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK ~j OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- L o-lb S S " 7 L B- Z b - o - C, Z. B- b 6- a a P- L- B- B- B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the la thg4ocation and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. ..r r a$ r ` i i .I fur C~ ,ir a j v i N f .S 1, the undersigend, 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) w Certification No. s~ -5,3--' Address O .Name of installer if known Copy A -Local Authority CST Signature s : State and County State Permit # PLB 67 - 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: TJ(?QIs B. LOCATION: Section T.4/ N, R or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) Variance Single family & Duplex No. of Bedrooms y No. of Persons D. SEPTIC TANK CAPACITY0AiCrO Total gallons No. of tanks I 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. EFFLU T DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. 1Vidth epth Tile dept!(t ) No. of Trenches Seepage Bed: -Depth--3 6 Tile depth (top) No. of Lines Seepage Pit: Inside iameter Liquid Depth No. of Seepage Pits Percent slope of land- 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 b the Certified/oil Teste NAME L jet ~y p(~ C.S.T. # and other information obtained from "7_4%.0-11-(owner/builder). Plumber's Signature r MP/MPRSW# Phone #Zy ta Plumber's Address 2.C. 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. E . Ee W_ rro _ E 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