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AS BUILT SANITARY SYSTEM REPORT
T' ~1
OWNER :'la f. TOWNSHIP/ SEC. ' T N, R ; W
P.O. ADDRESS y ST. CROIX COUNTY, WISCONSIN
SUBDIVISION_ LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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l~ I I ~ 1 h
1 I
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SEPTIC TANKS),; MFCR. CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
TRENCHES NO. of width length' area
BED no. of lines width length area
depth to top of pipe
AGGREGATE 1'
PERK RATE AREA REQUIRED AREA AS BUILT ?
Disclaimer: The inspection of this system by St. Croix County does not imply complete
compliance with State Administrative Codes. There are other areas that it is not possible
to inspect at this point of construction. St. Croix County assumes no liability for
system operation. However, if failure is noted the County will make every effort to
determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
t 'INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER
D=-PAR-r,4F%I' OF Ir4DU'.TRY, INSPECTION REPORT FOR SAFETY & aU,LDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS r, DIVISION
P.C. BOX 7969 BUREAU OF PLUMBING
NIADISON,Wb 53707
OSl CONVENTIONAL C_ ALTERNATIVE sI—P1-1.o.N~1.1 e1
11 r a,.,y„~;
Holding Tank ❑ In-Ground Pressure LI Mound
1; F 1?r PE w.11I 11 UDFESS OF PFRNI,-'1n. OFR INSPECTION DA-E
(-I
Pr'.CH AAARIL IP-11-1111 1111-1-- 01" DESCRIBE IF DIFFERENT FR-711V PI AN REF PT FI EV CST REF PT ELEV
n IE SActzy-u a- k i 8 my
r. P -,L- `I''f} 1,11' GI'It:.'N N,. Sar- y P--1 Nul' -
1 1 1 9 __7 L4
SEPTIC TANK/HOLDING TANK! , `I
mH^...I a: luulu L LIQUIJ Cn°r.CIT --"',1,K I.Lt [LE`.' T4M; OUTLET ELE`: IVIAIINIII-ABEL Ic,cKOJC.
_ OV JEO PRO ID
YES CNO YE F1 NO
-
HLI_1u1NG i VFN- DIA 'dLNr IJA1 L III ,"~'.A / ~NUMBER OF F64C F'R FEH l IL\'LLL/ V_] B11 DI V. YEN- TO FRESH
j GnV f ET FROM 4 F INLE,T
l-YES L_NOAREST
DOSING CHAMBER:
I,n •J11 ,1r_r IF~I~ IHEUUING LIOIIII: ;",[':\C P,~A1P '.11~p F.lr:' ,I>I. iV '.,;lt.I_.1 '~"tI,REI: ---1NnRN:NG LABEL LGCK INU COVLIt
PROVICEp. VRUV IU'_LI
DYES No DYES I7N0 DYES _j NO
GALLONS PER CYCLE: vr' ANU rr ,r I:i 0P tAt Jua1 INUMBER OF "H`' .'A _L BtnLDIN<, vENT Tr) ~ HLZa1
!DIFFERENCE BETWEEN FEET FROM aIH Nu
PUMP ON AND OFFI YES - NO NEAREST
SOIL ABSORPTION SYSTEM. Check thusoil moisture at fi depthoi Owing ""1,11 '`7AIKINr,
or eKCaVatiDn. (If soil can be -olled irto a wire, const!u nn shall cease until FORCE
MAIN
UTC su I rs Firy !'Hough to continue.)
CONVENTIONAL SYSTEM:
LI',.UID
1'." '1 I!NCi7.1 Ntl :7r rf[
BED/TRENCH riFNCFF: akr~k 'A PIT DIMENSIONS 5 5
I I I SILL L' FIR ',)ISrH PIF'F !11577 'IP' n1CTR P'.PF 41A7FRIA_ NC )I _,-I. T NUMBER OF P"OPERY" ELILCING V N TO FRES
n3,1` OVLH FI EV INLFr IIELF', I CJ~ P -FEET FROM N J~1, AIF IIIILET
---L YT ( 1 * -L EAREST
MOUND SYSTEM:
Mound site plowed perpendicular to dupe Check tf~e texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furroNN's thrown upslope: mound stems make certain that it ON REVERSE SIDE. SHOW ELEVA-
_ meep lne cri or um sand, TIONS MEASURED,
YES _ NO L-_
SOIL COVER FF - / - ~PFHtL •.ir.I V:.r;K IS:- v.: n: v ALL I
L IYES _-I NO IYES ONO
'i If?VF9 ThF',.. I-" F[, -PIII 1iilF`,: I•HI I. •nI PIH ^F_'F - -I. -I-1 sEEU[^
;
F L
YES nN0 DYES L~NOCIYES LINO
PRESSURIZED DISTRIBUTION SYSTEM: _
.1'11)111 LFi_', I H AO DF ~L4iEH! I-nV ACING iL CLVIH HL L:."lJ PI!l FILL :iE PTH :+,~..y
BED/TRENCH ILNEa1rs
DIMENSIONS
PL.\,P '.14NIF01 r: Lit n 1`11 NW FI:.I `JC) :1,StH IDI$-R. PIPE I)I'_;' FJi I1•, P I'I \..:I
F' ELEv D14 L V V'PES DIb.
ELEVATION AND
DISTRIBUTION
II'll L~ 1101, ;114f 11,16 E;Fill I11; )1111 "t r - - 111,1411 tIALIFTIIJ APPI- LD
MATION ES a YES G NO
COMMENTS. PERFAANLNt 1VANKLPS ONUMBER OF (PROPERTY WELL BUILDING
_ FEET FROM ILIr`E
vFS r`. CI NEAREST ------~~~fff
Sketch System On w- 13etair Mjrty fil-E1-f(T a-dit.
Reverse Side.
.nruRE nn F -
CILHR SBD6710 (R.01i82)
PLB 6 7 / State and County State Permit # I(- Permit Application County Permit #
fur Private Domestic Sewage Systems County
'DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY AMailing Address:
C, !7 4 W
B. LOCATION: Section pv• T N, R ctp ~ j tort 1,'V Lot# City
Subdivision Name, nearest ru.d, lake or landmark Blk# V Ilage
X/ G / I ownship 41(,1jMtA,1 C. IYPE OF OCCU ANCY: 'Commercal 'Industrial 'Other (specify) `Variance
Single family Duplex No. of Bedrooms ~ No. of Persons
D. SEPTIC TANK CAPACITY f 07-y Total gallons No. of tanks
HOLDING TANK CAPAC~I-Y Total gallons No. of tanks
Prefab concrete 2~ Poured-in-Place Steel Fiberglass Other Ispecify)
New Installation Replacement
L't Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. El Fl UENT ~SPOSAL SYSTEM Percolation Rate ( Total Absorb-Area. ~f S sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width eptp Tile de th (too) No. of Trenches
Seepage Bed:- C 30 Length__ ~-Width e_ Depth Tile depth (top No. of Li nes
Seepage Pit: Inside diameter Liquid Depth eL- No. of Seepage Pits Percent slope of land I Distance from critical slope
b'JATER SUPPLY: Private Joint LJ Community C Municipal C
:).vners name as listed on EH 115 if other than present owner.
I, the undersigned, do hereby certify that the nformation I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and tnat I have sized the effluent disposal system from the EH-115 preha•ed
by the Certif e Soil Tester,
NAME / e- J O -4 ~ y C.S.T. # I and other infnrmatio-
obtained from (ownerihuilder). Plumber's Siynat~re P; MPRSW# S Phone V,/- s y S
Plumber's Address
j 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 FOR COUNTY AND STATE QEPARTMENT USE ONLY
Date of Application V Fees Paid: State ~C County C~ Date ii- s ~ ~ ~J r)-
Permit Issued/Rejetne4 (datel t Issuing Agent Name {.,1~ . llYe~t
-oection Yes No State Valid* Date Rer•'ri
unty (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
)pink copy) 4, plumber (canarv cuuy)
1'.-p- rl F)ate 7/1,'78
DFPARTPJrNT OF REPORT ON SOIL BORINGS AND SAFLTY & RUI1 DINGS
INDUS'T RY, GG DIVISION BOX HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
ILOCATI N: SECTION: TON SHIPiRAUNICIPALITY LOTNO.:BILK .NO.:SUB IVISIONNAME:
~4/V 4 f Y /lJ'0N/RI L (nrl W o
-:0U TY UIi:NER'S~NUY'tH'S NAME: PAAI LING ADDRESS:
i `,T ,!~/ro d er 1r y, ke'iv
USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DFSCRIPri0N: PROFILE DESCRIPTIONS: PERC LA ION TESTS:
1VResidence I ~Ne.v ❑ Replace j` 1 13
RATING: S= Site suitable for system U= Site unsuitable for system
C NVENTI NAL: JU 'O IN-G OI D-PRESSURE: SYSTEM- N-FILL HOLDING N<: HECOMMENDED SYSTENI:(optional}
,S ❑u S ❑u S ~U EIS ;U ~S-NU ~ - „ hQ1
Percolation Tests are NOT required DESIGN RATE: If :lily portion of the tested m ea v; In the under s.H63.09(5l(b), indicate: F nodplaen, indicate Floodplain elevation:
w
PROFILE DESCRIPTIONS
BORING TOTAL D-PTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION 03SERVED _EST. HIGHFST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- ! 7~ If " e, 7F .I /-s 3Z) a e- 5 A,- 3 -
r
B- ;2
B- 91 7
PERCOLATION TESTS
TEST DEPTH WATER IN 110 LE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SIAIELLING INTERVAL-MIN. PERIOD 1 PEnIOD2
P PE INCH
P-
P
P_ I
P-
PLOT PLAN: Show locations of percolation tests, soil borincs and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are. the hori-
zontal and vertical elevation referencu points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope.
SYSTEM ELEVATION 7~ ~r
e6 C_ 1ref W_' G 3 .y •
~L7 D b ~
i
I, the undersigned, hereby certify that the soil tent; reporhed o.l this loan wf!rre made by me in accord w,th the procedures and methods specified in the Viisconsin
Administrative Code, and that the data recorded and the location o- the tests are corre;a In trip. bell of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON: )6z Hs
ADDRESS: / CERTIFICATION NUMBER: PHONE NUMBER(optiona'):
7i 5- ..2 w 5-iit '
CST S J UUU E.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and So • Ta.-w
Intl accurate Soil Lest, yo.;r rUport must Inch e.:
!npiete Icgal description;
use ,ertion must '";early indicdt%vvheIIIP.r tlIis k a I (-Sid "'nee UI CtimrflercIaI projec-; }
::IAXINIUNi number of be0moms or cornmvrcicii use }tlanned;
.hjs•a nowv nr rcp!acemert system; -n-nk-te th, s.iitaWIit•>+ rating hoXcm;. A SITL IS SUITABLE FC;H A HOLDING I ANK DNLY IF ALL
HER SYSTEMS ARE RULED OUT BASED O;v SOIL CONDITIONS:
-ASE use the c;bbfeviw iun~ shown here for vvi itinq wrtfile daXr:ptions and completing 1110 plot plan;
,KE A LEGILiLE riiagram accuratgly loudting your,teSi locations. D-avving to scale is preterrert. A
,_,~tairr sheaf may be uSerl f rfesirrd;
b:e -•are yr,ui b'nchrnark emi vel kcal cicvatior, ie'er,=nr-e point are cl-aly shown, an(j arc permanent;
nplaty all aopiopriall-p hoxcS ai in date' names. `kwd f) aln data, percoia-Ifln test eXernp- il, I' al)Ilfilpr411C;
lie Uitormation jS,:r!tt as flafx.l :.:lain, tlevtllic,nr deaf. clot apply, place N.A. i!t the .3ppiolgiate box;
a the farm and place your curre-lt address and your uertifif:at!on nurrt ?er
cc I rnihie rr,p:gs and distrihu'e as mquireri. Al J_ S0I1 f FS"S :UST BE TILED l^;ITH THE
Stolle BA Br-drock
f"nhi)l2 t3 - 10 SS - S'-?I r:e
,td iunt;ar X'I LS - Limt:;ton
1-4('-W - H;clh C;roundwatcr s:: Sd+tci Lerc °cr+::ulaEio;. Rate;
itrrn Sand V%1 - Ut,'rll
S~nti Bdu - 6uiidiny . -
ny Sand > - Greater -11,r1n
ly~ I rain Lt'ss Than
l Bit - Brfwvn
Loam I3l Black
Gy Gy L".-mui Yakiom•
y C:ay L, am t; - F'c`
Clay L:Iam m ,t ?t,ttlc: + Gray
CI t; fff tyv, ihle, faint ` '1
T~rany, it i`'dUn7
di;t nut -
promir,e~I>
Hirsh 1"'atut cdul,
s.:rfuce: water
11 tegt :s the tit,,-, st=?r, :n ;ectr"m(i Th,• cvu:Ity U~ the Dupartmer-t ;ndytNILIPSt
liv' of tl!is Soil t+.at i, .l,e fi^i<-1 I-A-iur 'r) pew if issutince, A i~„mpjete set nt pla'ls for the private
^.rn rrt ~t1C< a t.,.:!-r!?it arH •Ijr~tinrl rt, Ucr rig S..f,r--1r*:°:.I to tf,,• 1 : ir7;a1 J~-hn•"ii..• in nr;lr,t ~r.
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