HomeMy WebLinkAbout176-1025-60-001 (2)
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t AS BUILT SANITARY SYSTEM REPORT
OWNER' TOWNSHIP SEC.
~fA. _ T ~N-R W
ADDRESS 1/ r,) ST, CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
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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
BENCHMARK: Describe the vertical reference point used
Elevation A vertical reference point: Proposed slope at site:
SEPTIC TANJ~: Manufacturer: Liquid Capacity: Number of rings used: (0 Tank manhole cover elevation: y
rl~~ Tank Inlet Elevation: Tank Outlet Elevation: 2
Number of feet from nearest Road: Front,O Side, Rear, O 170 feet
]prom nearest property line Front,0 Side,aRear, O zo feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDI?
i
UMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inl Bottom of tank elevation:
Pump eff swi h elevation: Gallons per cycle:
Alarm Ma facturer: Alarm Switch Type:
Numbe of feet from nearest property line: ~ont,0Side, 0 Rear- ,0 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:
; J
Fill depth to top of pipe: v
Number of feet from nearest property line: Front, O Side, O Rear, FtJ
H
Number of feet from well: 1 00
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 rop box 0 or distribution box 0 been used on any of the above soil
absorbtio sytems? (Check one).
HOLDING TANK /
Manufacturer: / Capacity:
Number of rings sed: Elevation of bottom of tank:
Elevation of 'nlet:
Number of eet from nearest property line: FronO Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm 1anufacturer: - -
Inspector:
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Dated: 1 1`ry~ Plumber on job:
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License Number : 6-
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3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 796'I BUREAU OF PLUMBING
MADISON, WI 53707 M CONVENTIONAL DALTERNATIVE State Plan 1. D. Number
)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER' INSPEC ION DATE:
Herman Hoea2ey R. R. 1, Roberts, All 54023 _ _ 69
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. RE . PT. ELEV.: CST REF. PL ELEV
NW NW, Section 25, T29N-R19w, Town of Watften
Name of Plumber. IMP/MPRSW No. Coumy.. Sanitary Permit Number_
GI Steed. 3254 St. CtLoix 49486
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. T INLE E5V TANK O~JTLET E V.. WARNING LABEL LOCKING COVER
PROVIDED PROVIDED
OYES ONO DYES ONO
BEDDING: ~VENT VENT MAHIGH WAT R NUMBER OF RAD: PROPERTY ELLBUILDINGVENT TO FRESH
ALARMLINE _70 AIR INLETFEET FROM OYES OYES LINO NEAREST (
DOSING CHAMBER:
MANUFACTURER BE DDING. LIQUID CAPACI TV PUMP MODEL PUMP, SIPHON MANUF ACTUREH WARNING LABEL LOCKING COVER
PROVIDED PROVIDED.
OYES LINO OYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMB PROPERTY WELL BUILDING. I VENT TO FRESH
LINE AIR INLET.
(DIFFERENCE BETWEEN FEE RO
PUMP ON AND OFF) EYES ONO NE EST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LE t;rH DIAMETER MATERIgLANDMARKIN(,
or excavation. (If soil can be rolled into a wire, construction shall cease until FO CE
the soil is dry enough to continue.) M N
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH No of DISTR PIPE SPACING cov JINSIDE DIA t a TRENCHES M PIT DDIMENSIONS ,RAVE L DEP FILL DEPTH DISTRPIPE TR PIP
DISTR. PIPE MATERIAL NU DI H NUMBER OF POPERTY BUILDING: VENBELOW PIPES ABrO VIE COVER E V IDLE FLEV E J ''7 q PIPES FEET FROM I LINE. AIG 2.
Zi ` / ( Z NEAREST MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DI RAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVER IDE. SHOW ELEVA-
meets the criteria for medium s Ind. TIONS A RED.
OYES ONO
P NENT MARKERS BSERVATION WELLS
SOIL COVER TEXTURE
EYES NO DYES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL S ED DED MULCHED
CENTER EDGES
❑Y S ❑N ❑Y ONO EYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERAL SPA G. GRAVELD PTH BELO WE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. E MANIFOLD ATE AL. NO. DISTR. DISTR IPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.. ELEV. DIA. ELEV PIPES. DIA.:
ELEVATION AND
DISTRIBUI ION VERTICAL LIFT CORft ESPON DS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORREC V COVER MATERIAL pLgNS
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LPINEROPERTY WELL BUILDING:
FEET FROM .
S EYES ONO OYES ONO NEAREST
0 IF.
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Sketch System on da,c unty file for audit.
Reverse Side. SIGNATURE ~i TITLE.
DILHR SBD 6710 (R. 01/82)