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AsJDRESS - ' SEC. T N, R W ST. CROIXCOT,7NTY, T„ISCON IN. '13DIVISION LOT Z1. LOT6 SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i 1 -TIC TANK(S) MFGR. i . CONCRETE STEEL N0. of rings on cover DepthDRY WELL 'NCHES NO. of width length area no. of lines width length area depth to top of pipe , REGATE dK RATE 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 j / 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, ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. "INSPECTOR DATED PLUMBER ON JOB 1 LICENSE NUMBER z - REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.itatcy PvLm.it State Septic NAME Township S-t. Ctcoix County Location % o6 Section. T_N, R W SEPTIC T,.4NK Size ga tont6. Numbers o6 CompaAtment6 D,ibtance Fnom: Wett 120 otL gtceatet zZope it Bu.itding it. wettandts it. H.ighwate,t it. DISPOSAL SYSTEM Diztance Ftcom: Wett it. . 1 2 0 on gtceateA 6Zope it. Bu.itding it. wettands Ft. H.ighwatetc it. FIELD DIMENSIONS: Width ob ttcench it. Depth o6 tcock below t.ite in. Length ob each tine it. Depth o6 Aock oven t.ite .in. Numbers of tines Depth o6 tite below gtcade in. Tota . kength o j 2.ine6 1c)t`) it. Sto pe o6 ttcench in pen 100 it. D.ustance between tines it. Depth to beds ock it. Totat abtsonbtion atcea 9612 Depth to gtcoundwatetc it. 2 Requited area PIT DIMENSIONS: Numbers o6 pits Gtcavet atcound pitz yes no Outside d.iametetc it. Depth betow ,intet it. 2 Totat absotcbtion atc.ea it z A 2 A&ea tcequktced it "y INSPECTED BY TITLE APPROVED ,DATE 197. ,w REJECTED DATE 197 - ^ EIS 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: Section (:R-7, T3A, R~29Wor)Wfownship r Municipality 41, Lot No. Block No.~, ty, ~.Oi ~u County Sub ision Name Owner's Name: Mailing Address: Y [ ak -mod 'l '4 14'7 Z"_ TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS 7--'22-- _---~c41 SOIL TYPE .S_t A-/ SOIL MAP SHEET 0 PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 M IN/IN P_ let 3 -3- W 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) - r ~ ;WC; ;A c, e, s 1,2 Akxt e--- B- f PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square f e{}} f Suitabl/e areas. ndi,to nun hel cif ,qu/~,n p fee' c,f ah nrpric,n ;ii ea needed for building type and occupancy. 4l Y~'. ~1 S'0~ je9r _e-e'4 Indicate scale or distances. Give horizontal and vertical refere p ints indicate slope. Foy.-rs~ i E r i 1 3 i 1:3 ~c V I T1 M i =/1G`LZ T t N i I a - - L I, the undersigned, hereby certify that the soil tests reported on this form were mrade by m"e in accor 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 nowledge and belief. Name (print) Certification No.~ Address t^ C Name of installer if known CST Signature-- ~y COPY A - LOCAL AUTHORITY v State Permit # PLB67 State and County - Permit Application County PermJ~ # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER QF PROPERTY Mailing Address: 4L ~ B. LOCATION: 4-~.,)1/4 Aje- Y4, Section 6R_7, T 3Q N, R' C V (or) of#+r City- Subdivision Name, nearest road, lake or landmark Blk# Village -te- Township S '14i~?~ C. TYPE OF OCCAdM"Com merc ial *Industrial *Other (specify) *Variance _ Single family L Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher )e YES NO Food Waste Grinder YES_XNO # of Bathrooms L- Automatic Washer _X-_YES NO Other (specify) E. SEPTIC TANK CAPACITY 1C0%'-1 Total gallons No. of tanks l _ *Holding tank capacity Total gallons No. of tanks ~e___ New Installation Addition Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) - , . EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) , 2) 3) _Total Absorb Area sq. ft. / N,ew Addition Replacement C *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length -Width _IV---Depth Tile Depth -7C cc No. of Lines Tile Size ~r Seepage Pit: Inside diameter Li uid Depth Percent slope of land O Lr~ 4,/Y Distance from critical slope 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 Cer ied Sol Te (er, C.S.T. # and other information NAME 10~', / obtained from C caner/builder) Plumber's Signature MP/MPRSW# Phone #7~ / Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). I~~vJ?~/~C'Cf . ko E4 rlvo> a ~l~eS• ~~yr.~L, _ N~l 3 Do Not Write in Spa Below_ FOR DEPARTMENT USE ONLY Date of Application Fees -~Paaiid State (9 County Date Permit Issued/IgjeeteeJ• (date) Issuing Agent Name Inspection Yes4-1No 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 6/1 /76