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CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of II 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4 r i I i i `4! I i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used fn 'i Elevation of vertical reference point: Proposed slope at site: SEPTIC TANI:: Manufacturer Liquid Capacity: Number of rings used: Tank manhole cover elevation: y) Tank Inlet Elevation:Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side ,0 Rear, O feet From nearest property line Front,0 Side, (D Rear, _ feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) S1111'. -004 AK 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, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: }L Trench: Width: Length:_-(Number of Lines:_ Area Built: rFill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, O Ft Number of feet from well: 'i 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 .^f 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 rianufacturer: Inspector: Dated: Plumber on job: r- License Number: 3/84:mj DEPARTMENT GF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, IVI' 13707 ❑CONVENTIONAL ❑ALTERNATIVE State Plan I ,D. Number. II/ assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound . INSPECTION DATE. NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER LL"tr tom; :te f / 'F SS tZ.zi a ~G.f ~a rP7 / /17 BENCH MARK IPermanem reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV NE- Ally Na- of Plumber. IMP/MPRSW No. Cou my Sanitary Permit Number: / I~0 rs S~ ~X y 9Sv6 SEPTIC TANK/HOLD NG TANK: MANUFACTURER LIQUID lA TANK INLET ELEV. TANK OUTLET ELEV. ARN G LABEL LOCKING OVE P O DED. PROVID J YES LINO ❑ E O BEDDING: V`NT DIA IVE11-T MATL HIGH WATE NUMBER OF ROAD. PROPERTY WELL: BUILDING VENT TO FRESH ALARM FEET FROM L AIR INLET. DYES LINO DYES LINO NEAREST e~~~ r T DOSING CHAMBER: MANUFACTURER JBEDDING. LIOUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED PROVIDED DYES LINO EYES LINO DYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL M ER OF PROPERTY WELL BUILDING (VENT TO FRESH (DIFFERENCE BETWEEN FEE FROM NE AIR INLET PUMP ON AND OFF) DYES LINO NEA EST SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing ,U r, DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until ORC the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH JNOOF DI-7R PIPE SPACING COVER INSIDE DIA -PITS LIQUID BED/TRENCH TRENCHES / aL PIT DEPTH DIMENSIONS G GRAVEL DEPTH FILL DEPTH ~FLFTI"IPJ'LIT S. PE DISTR PIPE DISTR. PIPE MA RIAL N DI NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES ABO CO R ELEV.END PIPES" z FEET FROM LINE © AIR INLET. S' ( 2C ~ NEAREST 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. EYES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ❑ DYES NO DEPTH OVER TRENCH BED DEPTH OVER TRENCIT'BED DEPTH OF TOPSOIL SODDED SEED JMULCHED CENTER EDGES. DYE DYES NO DYES NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING. GRAVEL PT BELOW PIPE. LL DEPTH ABOVECOVER. BED/TRENCH TRENCHES. DIMENSIONS / PIP SISTR. DI TR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING MANIFOLD PUMP MANIFOLD DISTR. PIPE MAMA ERIAL. NO ELEV.'. ELEV.' DIA. ELEV.'. DIA.: ELEVATION AND DISTRIBU7 ION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING CHILLED CORRECTLY COVER MATERIAL PLANS DYES ❑N DYES LINO COMMENTS: PERMANENT MARKERS: OBSF ATION WELLS: NU ER OF L NEERTY WELL: IBUILDING: FEE FROM 3 L DYES LINO DYES LINO NE REST q G C' Sketch System on RetaiTTirs-counT74ile for audit. Reverse Side. SIGNAT TITLE./r) DILHR SBD 6710 (R. 01/82) APPLICATION FOR SANITARY PERMIT I LHR COUNTY 7:::: (PLB 67) UNIFORM SANITARY PERMIT # TRn RELRTIOns 9so& -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8%2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER - MAILING ADDRESS PROPERTY LOCATION CITY: 4. 1144 il. 1/4, S Cis T N, R 'W(or) W TOWN OF: t. 4 LOT NUMBER BLO/C/K NUMBER SUBDIVISION NAME NEAHLS T ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: . ❑ Public (Specify): THIS PERMIT IS FOR A: "K New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ! Q Private Joint ❑ Public I, the undersigned, hereby assume responsibility for installatio-n of the private sewage system shown on the attached plans. Name of Plumber (Print): Sipnaturw W/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Disapproved Y fL~ %t ❑ Owner Given Initial T-1 Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber f INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT S T C - 100 This application torn is to be completed in full and signed by the owner(s) o1- 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 decd recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner uJ Pro ci-Ly r L y location of Property Section `h N - R ~7 W Township 51.¢yY,06•--1 Mai 1 ing Address _ ~ _-----540 . ----r-- ~ ~ Subdivision Name Lot Number Previous Owner of Property lN, /y Total Size of Parcel Date Parcel was Cr.~...,d Are all corners and lot lines identifiable? Yes No is this property being developed for resale (spec house) Yes JK_ No Vullilt e and Page Number "71.~ as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed Land Contract- 3. Other recordings filed with the Register of Deeds O-lTice In addition, a certified survey, if available, would be helpful so as to avoid de1_ays of the reviewing process. If the deed description references to a Certified Survey Mal,, the Chu Cart i + led purvey Mal; shall also he required. PROPERTY OWNER CERTIFICATION fmowk'ed vekti6y bedAinythilsn) ~thatt Ier (we) { am (acre) the'Jowncs (.a) (lorl the the best 9 k4osmati.on 6onm, by vixtue o6 a wabAan.t;y deed neconded in the Ollice cA the County Registers o A Deeds as Document No. and that 1 (we' pmentby own the proposed site bon the 6aeage dci~Cw~aP~Sysxem (on T (we) have obtained an easeme.n.t, to nun with the above deocki..bed pnopolty, 6otc the conztauction o{I said system, and the sane has been dAy Atconded in the OAAice u6 the Count( ReQtest o~ Dee.cs, as Docurne.n,t No. ) . c •ZrZ.~- ' SIGNA'T'URE UV OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DACE SIGNED DATE SIGNED H ' y r S C - 105 r H Sl?I''1'lC TANK MAINTENANCE ACREEMI';NT >t. Croix County d y H OWN1:R/BUYER ROUTE/ BOX NUMBER Ai y/~ Fire Nu~m/ber- C I 'I' Y/ ST AT E 'l. 11, - - G- 1'RO1'ERTY LOCAT10N`-4, !4, Section l ~ N, R / W, Town St. Croix County, Subdiv is n Lot number Improper use an"l maintenance of your sept. it :;ysteni Could result in its premature`lailure to handle wastes. P1oper maint(2nance. con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank 1)uill pej- What You put into the system can affect the function of the septic tank as a treat - ment stage in the waste disposal system. St. Croix County residents maw be elig.ibIc to recci.vo a grant fur a maximum of. 60% of the cost of replacement of a fa -i.iing system, which was in operation prior to July i, 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 H three year expiration. o I/WE, the undersigned, have read the above requirements and agree v) to maintain the private sewage disposal_ system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- 'e meat 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. i SIGNED C4/~ D AT E 5 e7 St . Croix ;aunty Zor,illg Of 1 ice Y.O. Box 95 llammc nd, W i 54015 715- i 96-22 39 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 539069 HUMAN RELATIONS (H63 09(1) & Chapter 145.045) TION. YV~/ SECTIO~TN/R1•1E(or TOWNSHIP~UNICIPALITY: LOTNO.:BL.NO.:SUBDIVISION NAME: COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: t ~t6 k r .h Y USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence New ❑Replace / - 1 r gQ RATING: S= Site suitable for system U= Site unsuitable for system s CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) NS ❑U S ❑U MS ❑U ❑ S ®U ❑ S ZU 0,0 J hJ_ i un a I If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: ( I Floodplain, indicate Floodplain elevation: ~(i) S hL'efi SC ~1 } I ~iL J, (t y,FOFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 7B~t r~-s~~s savs;~ B- ~Ll 78y 9 3LS' - ~ ySL S; 4/ SL B- ~y ~8y U-5134 S S - SL B- 0-6 8~6 B-,5 g y U Ll 63A - a 1 15 L- '~2 y S L- B- 0 6 R 4 S c, -DAS'L_ --),9-89 SL PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ f i-% 3 C~ l g %8`f P_ is~ •5~ e 3:~ P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference 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 /00 r A (Ieneh Mark,, F_ le jai ~v►s - X Where . eerc wazs Ta ke.r+. wo-__ . SGT le, rH TN Ct_ 995 C , , 7 ©f]'KL~!l G~ z ya~A D ~r9 t~ ~ f , )eFE _ (El-/00 w_ , 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: UWA/ LL ADDR S: CERTIFICATION NUMBER: PHONE NUMBER (optional): / f Lt ti' D ~ 'y 0 / 7 aC 3 Z~ CSk IGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - A anfI c?£.F aria 1¢ 'C>ut d"El 3t47*$: trst Yr"£x"iir 3v. use s„1>> ion rnu,g ~ y indicate vjh~e ,it H m, i.x <; a~~ ...rc«~rF project., rujrnbe isT Si I'3O rt}z .".3?" G<} aix ...,CSi 3 t r;a :g Cited e.,tt,f o. ( #g'YS ~f rs t. for t r"u fi R `.aY S i0... A,R 4. RR7i. fli T „z» VO F.D ri>i .'3O xi.., C{.%N~ S t th i)bi 1; t ~'7 r E F £ pi `Exf'. E l 8],`rtf€ t s11"' completing the Plot A LEGIBLE SLFr» jJ nr.t rnar k <wvl f Y x ica! + CY a i 7k e pe# m-aC'€¢ is t}: z.: . it p ,t7i:ma- eVlnx " te .9. p=;f 7YtO- a3 P 1 w L; if -ta, .y e .,,T- 3 [-3 R be, i € f n.-,aY G~avci (L'odlur T'; Ls ~L~ e s 4 a - )Y e 3 x J' I"I Sill L"'~Qrl~ a~ tin vr ir.Y.no t ,t„6if 4 ,BSI r. ~ . 'f 11E(r A , . i 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 ,T_N,R_E (or) W, Township or Municipality Lot No. , Block No. County Subdivision Name Owner's/Buyers Name: Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET NAME OF SOIL MAP UNIT 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- P- P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- B- B- B- B- B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location 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. 4~, z E , a s 3 ~ ' j , I ~ , s ~N 4 4- . _g 1 € i , F E f ~ !jI E e t 4 E ~ ~ e z e 3 I, 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) Certification No. Address Name of installer if known Copy D -File Copy For Soil Tester CST Signature I I PAGE OF 1 0 r1 p 1 "l Fresh Air Inlets And Observation Pipe t__l` Approved Vent Cap Minimum 12° Above Final Grodo 20- 42° Above Pipe _ 4° Cost Iron To Final Grade Vent Pipe Marsh Nay Or Synthetic Covering min 2" A.ggregul• - Over Pipe Distribution - To Pipe 0 0 0 0 0 te o Perforated Pipe Below ki" Beneath ega Pip e Be o -Coapling Terminating At • Bottom Of system r~ SOIL FILL DISTRIBLITIOVI PIPE g SI~TM PPROVEO ETIC COVER ° '~'-MATERII~! OR 9" OF STRAW 2"oF hGGREGA1c OR MAKSU HA`U (oOF%2-2.Ilz AGGREGATE ELEV. of/,r FEE~"~ DISTRIBIJTIO►J PIPE TU BE AT LEAST IIJCHES BELOW ORIGIIJAL GRADE AIJ[J AT LEAS-I-20 IUCHE~ BUT AIO MORE THAI) H? INCHES BELOW FINJAL GRADE MAXIMUM DWH OF F-XCAVATI00 FA011 Mi&vvu 6KAK- WILL BE ly I"CHES MINIMUM ()Qr'1i OF EXCAVADOW FKal- 0 ►161WAL (3R49ji WILL 6E INCHES SIGIJED: LIC E►J SE KJUMBE R: I DATE: ! . FT- Ile, ~s I r I 111 } ~ t- - ~Jda.L. - F r REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM Sani tzd.y P('Amit 133- State SeptA_ 9D NAME Township ~'w• _St. Ctcoix County Location -Section Lot # Subdivision SEPTIC TANK Size gaUons Numbed. oA eompattments Distance Atcam: WeU Buy eding 12% s dope Highwated PUMPING CHAMBER Stize, gaf-fo ns - Pump Manu Aaetu)cetc Mo deb Numb etc. HOLDING TANK Size gattons Numbete oA CompaAtments Pumpeh_ - Atahm System DMAtanc(, Anam: Weft. Building 126 sfape_-- H.Lghwate_.4 ABSORPTION SITE Bed Treeneh Distance Atom: Weft-_ Butitding _-t2o scope - Highwatett ABSORPTION SITE DIMENSIONS Width oA tdench At RequA.Aed aAea A,t Length o6 each fine, At Depth o6 4o eh b etow ti. e in Numbed oA tines Depth oA hock overt -tile. in To,taf length oA tines At Depth oA ti e betow gttade in Di,5 Lance. between eine/s At S tope oA tttench cn. pet 100 At TotaZ abAodption area At Type oA Covet: Papet od. ststaw fTI PIT DIMENSIONS Numb en o o pits Gttavet astound pis yes n0 Outside diameten At Depth below in.f-et A) t Tota-t absoscpt-Lon astea At Aea de.qutided At INSPECTED BY TITLE APPROVED DATE 198 REJECTED DATE 19 8 REASON FOR REJECTION REPORT ON INSPECTION OF SANITARY PERMIT # (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Time of Inspection ame, ress, License No. o ns a ing plumber (3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO ; 8 HOLDING TANK: Manufacturer o gallons construction ; depth to the cover ft; If septic tank is being used are baffles removed? ❑ YES ONO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? ❑ YES ❑ NO; Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than Z0% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TREN H: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095 N.05/80 Signature of Inspector: En 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:'/4,A14LY4, Section J,T.UN,R.a j (or) W, Tower ip or Municipality 6Z' Alrr" Lot No. , Block N0. County Cla Subdivision Name Owner's/Buyers Name: c Mailing Address: TYPE OF OCCUPANCY: Residence- No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT -ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 2n PERCOLATION TESTS SOIL MAP SHEET NAME OF SOIL MAP PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES I NUM- DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTE INTERVAL RATE MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P J 16-1 /3 1 S P- ,I II 116 JVQ Al L~ 30 P- )t 4 Ali? 41,6 -10 P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- , C3 r B- S~ B- 7 B- B- S, 21 - SLSL B- ? PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the to a)ion and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy r .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. 11 , 'I Soa_ CI~V&i 4&1 h/ Puza p w. - LPL 99, S' - r-- - F A)AP f t~rE IOC? 9 I d R f ( ) 6 i § i I I s a ~ ~ ` ~ i t s t I 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. ~I Name: II iint)__ Certification No. s': Address ~ Name of installer if known Copy A -Local Authority CST Signature State and County State Permit # PLB 67 _ Permit Application County Permit # for Private Domestic Sewage Systems County a *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 6/ j ~ B. LOCATION:-'/4 Section , T / N, R_ g (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township S7-44LE12 I C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family X Duplex No. of Bedrooms -No. of Persons D. SEPTIC TANK CAPACITY^f(?C)Q Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete _ t Poured-in-Place Steel Fiberglass Other (specify) New Installation X Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate To al Absorb Area 7~G sq. ft. ~~La New X Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth -,('t~op) No. of Trenches ;-No. of Lines e Seepage Bed: y_Length _4, j + Width Depth Tile depth (top) c Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land C Z Distance from critical slope WATER SUPPLY: Private 5< 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 o C.S.T. # and other information obtained from I m! "r (owner/builder). Plumber's Signature " MP/MPRSW# /L Phone # Plumber's Address r 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. 1: WC,,q )C11 to p 'JlrO E ; e } 30o s.a his 4 a , 3 ~ E E ~ E 7 s.,_ _a.__ a._.- ..t _ t t F I E ~ e e a. ) gym. i„-.e.m,,. e. . ..a.,y_ Ar~ . . _ W®. ..a,.~.__..m. 4. .r _ Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application Fees Paid: State County - Date e~ (date) ~ - - Issuing Agent Name Permit Issued/R 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