HomeMy WebLinkAbout036-2006-70-000
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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER --r, TOWNSHIP SEC. T N-R~W
ADDRESS \ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT / LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
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BENCHMARK: Describe the vertical reference point used 16I
Elevation of vertical reference point: ~C Proposed slope at site:
SEPTIC TANS: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:'
Number of feet from nearest Road: Front,("") 041.- Rear, D- js- feet
From clearest property line Front, 0Side, (D Rear,0 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SFI? i~ ?Vl?RSI. 511)I~
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: Trench:
Width: Length:
Number of Lines: Area Built:
Fill depth to top of pipe: ~J
Number of feet from nearest property line: Front, O Side, ® Rear, O Ft
Number of feet from well: Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepag, 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 of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, Q Ft.
Number of feet from well:
Number of feet from building:
' Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated. Plumber on job. 6 ~fir~C ( l C~i~
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. SOX 79< 9 BUREAU OF PLUMBING
MA?ISON, WI 53707 `
JMLONVENTIONAL ❑ALTERNATIVE IS,,,, Plan I,D' N,mber:
(If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
GjUjam WinchateA, Jn. R. R. 3, New Richmond
BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
NE SE,Sec.31,T31N-R17W, Lot#37,Oak Rdg.Est.,Town o6 Stanton
Narne of Plumber. IMPIMPRSW No. County S.nn y Permit Number_
Cat Poweu 1563 St. Cnoix 54901
SEPTIC TANK/H LDING TANK:
LIQUID CAPACI V TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
MANUFACTURER
q , ~ PROVIDED'. PROVIDED.
DYES ONO DYES ONO
BEDDING: VENT DIA.. VEN MATL. U M BF ROAD PROPERTY WELL. IBUILDIN TO SH
rIGHWATER
LARM. EE.. IVENT
AIR LE
OYES ONO EYES ONO 'AWA T LL" L
DOSING CHAMBER:
MANUFACTURER. 7ING L IQUID CAP ACITV PUMP MODEL PUM 'SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES NO DYES NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS ERATIO AL. NUMBER OF PROPERTY I111111 BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth plowing JLENGTH 1111AVETIII MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall ease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LE NGTH NO. OF DISTR. PIPE SPACING COV INSIUE DIA >t PITS LIQUID
BED/TRENCH ~ TRENCHES f roiAL: PIT DEPT"
DIMENSIONS 6 5 f
GHAVEt. ()FpTH FILL DEPTH GIST R. PIPE DISTR PIPE DISTR. PIPE MATERIAL: NO D H NUMBER OF PROPERTY' WELL. BUILDING. VENT TO FR H
BE LOW PIPES Aar Ecv R ]ELL INL&r ELEV END PIPE FEET FROM uN AIR
L .L ?L.L,o~Q--T NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ONO DYES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH: BEL) DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
DYES ONO DYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DIS THIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA.. ELEV.' PIPES' DIA.'.
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
DYES ONO pL NDYES ONO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OROPERTY WELL: BUILDING.
FE. FROIQ uNE
L~ DYES AREST
~OL DYES NO
Ct.1 t
4 t 9 og
Sketch System on tp etain in county file for audit.
Reverse Side.
SIGNATURE- .r TITLE.
DILHR SBD 6710 (R. 01/82) " a.
wlsconsln APPLICATION FOR SANITARY PERMIT
,D I L H R COUNTY
(P LB 67)
~ oeRRRTmenTOV UNIFORM SANITARY PERMIT #
- In0U5T RV, LR60R 6 HUMRn RELRTIOnS 16- q y
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNED MA~41NG ADDRESS
/Z /Z 1VZ'1j 47 -V
PROPERTY LOCH ION "T-Y:
Wt~L1kG E :
144 1/4, S_ , T- 7j, N, R (or) W TOWN OF:
LOT NUMBER BLOC " NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
Ld 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): r
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
Alternate System ❑ Reconnection ❑ Petition for Modification
IF TIJIIS 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):
X 1 /
Private El Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of private sewage system shown on the attached plans.
Nayrrfe, of Plumber (P fl- Sign at e: MP/MPRSW No.: T(h,,/,e Number:
Plumbpns Address: Name of Depgner:~. l
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
} 6 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
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 FOIL SANITARY PP;IZMLT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of 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 deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property U',.- t ,i., r 14 , 1 r~ ~•-k -
Location of Property ,~)V_ 4 ~4, Section s 4 T N - R W
Township
Mailing Address
r - F,z
Subdivision Name
Lot Number.
Previous Owner of Property 54r/ t A
Total Size of Parcel
1
Date Parcel was Created w 12
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes V- No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
0fanty Deed
2. Land Contract,
1. Other recordings filed with the. Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRY OWNER CERTIFICATION
7 (CUe) centily that aXT 6tatements on this loom ane_ true to the beAt o; my (outs)
Onowtedge; that I (we) am (and the owners (b) Q the pnopent_y deAetibed in th.0
in{)onmation loam, by vintue of a wannanty deed necoaded in the OjAice oA the
County RvyiAten oA Deeds as Document No. . V- f / , and that I (we)
rame.ntty own the pnopoAed site {ion the towage disposal system (on 1 (we) have
obtained an easement, to nun with the above descoibed pnopenty, loo the
conMuctcon oA said sybtem, and the same has been duty neeoaded in the OAlice
of t;ie County Regi6ten oA Deeds, as Document No. ) .
r
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE S1GNEI)
H
DO
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S T C - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
d
9
OWNER/BUYER
ROUTE/BOX NUMBER j _ -Fire Number - _
-c`,- -
CITY/ S`'ATTE' Z I P
PROPERTY LOCATION: 1 '4, Section ' TN.
Town of St. Croix County,
Subdivision +r' 00 Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. 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 may be eligible to receive a bract for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 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
three year expiration. H
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart- 'ti
ment 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.
SIGNED
DATE
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR .AND PERCOLATION TESTS (115) MADISON W1 969
HOMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/Mb'NICIPALITY: LOT NO] LK. 0: SUBDIVISION NAME.
IV' /Ty N/R>- F (or )W ,~f i 13 7
;,I~r-
C UNTY. OWNER'S/BUYE 'S NAME: MAILING ADDRESS:
USE DAf S OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑ New Ql Replace
RATING: S= Site suitable for system U= Site unsuitable for system 1411) 't
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILCH DING AN K: RECOMMENDED SYSTEM: (optional)
S ❑u 1Z S ❑u ❑ S ❑U ❑ s ZU ❑ S ~U T,>
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: Floodplain, indicate Floodplain elevation: A/r
PROFILE DESCRIPTIONS fYs
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEWFH fN,I EVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
7/a S
S IRI)
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t PERI PE 3 PER INCH
P-
P-,
7Z_
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 3
7k 1k
71 -
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E
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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.
NAM print): I / TESTS WERE COMPLETIED ON:
_Ix
A R,ESS: / CERTIFICATION 7ER: PHONE NUMBER (optional):
17
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` ~J~ CST N URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
D!I HR-SBD-6395 (R. 02!82) -OVER -
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PAGE OF
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7
Fresh Air Well, And Obcerrallon Pipe
Approved Vent Cup
Minimum 12 Above
Final crude
2U - 42" Above Pipe _ 4° Cael Iron
To Final Grade Venl Pipe
Marsh Hoy Or Synihellc Covering
Min 2° Agg egale
Over Pipe
Olelrlbullon
Pipe 0 0 0 0 0 Tee -
b` Aggregote
Beneath Pipe 0 Perforoled Pipe Below
o Coupling Terminating AI
Bollom of Syelem
~tr,~a.-4-
SOIL FILL
DISTKIBLITIOf.) PIPE SyuT~
APPROVED ETIG DOVER.
'-MATF-RiAX OR 9" OF STRAW
2"oFgGGREGAfi~--'~ c / ORMARSN HAy
oo ~
6o CAF ? /Z AGGREGATE
ELEV. aFj_,` FEFT~
r
DISTRIFj1JTI0KJ PIPE TU BE AT LEAST i1JCHES BELOW ORIGIIJAL GRADE
AKIU AT LLAS-T-20 IfJCHLC BUT KIO MORE -THA~J `12 WCHES BELOW HUAL GRADE
MAXU"ItJM ®EPT►i OF F-XcAvAT►m►.➢ Rom b►{iGrNqL 6KADF- WILL BE
MINIMUM ®CPr►t Or FACA%/AT10N fKOM OX61114QL GRADE WILL pE 31~ INCHES
SIG1.1Ep:
LIGEIJSE UUMBER: Y -3
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AS BUILT SANITARY SYSTEM REPORT
OWNER f TOWNSHIP. SEC.. T N, R W
P.O. ADDRESS 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
• i
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SEPTIC TANK(S) N['GR. 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
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.
INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER
RRPOI;T 0F IPT5PEC'].'IO'_1--1:MJID(7AI, SE.411GE DI.,P0S11I~ SYS;.Eii
Sanitary Pel.7ihit
State :peptic
VIE
T&INSHIP
• t. Croi~ County
SEPTIC TA'?1:
S) i ze gallons. `lumber of Compartments _Z_,
Distance From: WeII _ft, 12% or greater slope -'Jfi.
r Building ft, Wetlands ft
I1i.ghwater ft.
DISPOSAL SYSTL:1 X Tile Field or Seepage Pit(s)
Distance From: Well ft. 12%, or greater slope ____f t
Building ft. Wetlands f:
FIELD Highwater ft.
Total length of lines ft. Number of lines Length of
' -,each line 1. 5 ft. Distance between lines ft. Width of the
7 '
rench ft. Total absorption area ~l `sq. ft. Depth
of rock below the in. Dp-pth of rock over the in. Cover
~l.
~ove:r. . rock ~t t Depth of tile below grade,- ~ in. Slope of
trench ner 100 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS
Number of pits Ou Jil di er ft. Depth below inlet
ft. Gravel aroun i des no. Total absorption area
sq. ft.
.Square feet of seep~p;e trench bottom area. required
%Squars feet of se~pa r t a r uired
Inspected by: et t ti Title': n?
Approved Date J 197.
Rejected Date 197
State and County State Permit #
PLB67 Permit Application County Permi -
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:
2O
C_ tie per ~Ll~., wl
B. LOCATION: ~Y4 L•-j Section 3 1 , T_3~1_ N, R.1 7 E (or) Lot# City
Subdivision Name, ~ nearest road, lake or landmark Blk# Village
Township ST/¢r!T ato
C TYPE OF UCCOPANV Y: *Commercial *Industrial *Other (specify) *Variance
Single family _ x _ Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher _>L_ YES NO Food Waste Grinder YESXNO # of Bathrooms-/-
Automatic Washer YYES NO Other (specify)
E. SEPTIC TANK CAPACITY / 00 G Total gallons No. of tanks /
*Holding tank capacity Total gallons No. of tanks
New Installation Addition _ Replacement _ Prefab Concrete A-
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) L 2)3) s7 Total Absorb Area sq. ft.
New k Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length S Z' Width 12.1 Depth L-l Jz Tile Depth 3 Z- " No. of Lines 2
Seepage Pit: Inside diameter Liquid Depth Tile Size (-1
Percent slope of land 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 I
by the Certified Soil Tester,
NAME C-*[, (i l el ~G w a rs C.S.T. # ' S 5'3 and other information
obtained from c? c..iyi c t 1 (owner/builder).
~X,Plumber's Signature MP/MPRSW# % S-~ Phone # Y yb sl 3 S~
Plumber's Address-
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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63 LI)
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Do Not rite in Space elo FOR DEPARTMENT USE ONLY
Date of Application ' Fees Paid: State, Chou Date
Permit Issued/ (date) Issuing Agent Name
Inspection Yes No 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)
EH 1.15
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: lV4f%, _'/a, Section 3 , T3 /N, R j_~E WKV Township or Municipality 5 7`-4!9"-7 T f'2 - -
County
Lot No. , Block No.
ubdivision Name
Owner's Name:
Mailing Address: t G~
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW x ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOILBORINGS -7 7? PERCOLATION TESTS
SOIL MAP SHEET 3`1Y SOILTYPE
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER SOIL SINCE HOLE HOLE AFTER INTERVAL
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P 2. G i' d
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~-3
SOIL BORING TESTS
TES1 TOTAL DEPT i t DLP i rl TO G it_?Uf C?~+A'? INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
76 - 7.5 2- V , L c;-~G S
-3 9
y E o -ors S
z67 F 2-0 3 - ~c
l~ 0 -47S 6- Z0 SG zV °-yG
3-
P_AN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
dicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
nr eded for building type and occupancy. 5 IS Indicate scale
or distances. Give horizontal and vertical refer even points. Indicate slope. 14L / zj, YeJ
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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
w the best of my knowledge and betiraf~
Name (print) /LJ v > Certification No. S- 9-_S_ 31L
address r, '
of installer if known ;
CST Signature ^
-0-Pt A -LOCAL AUTHORITY _