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ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner`
Address fly
City /State # t
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Legal Description:
Lot _ Block ` Subdivision/CSM #
4 Sec.T N -R W, Town of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer w2 is 4 r Size STAY Q /2-9 Setback from: House /Z Well P/L >,f
Pump manufacturer Model
Alarm location
H ING TANKS ONLY)
Setbac ervice road Vent to fresh air intake Water Line
Meter locatio
Alarm location
SOIL ABSORPTION SYSTEM
Type of system re Width J Length Number of Trenches 3
Setback from: House Well 5 50 P/L T z5 Vent to fresh air intake Pmo'
ELEVATIONS
Description of benchmark 15'1.2 f Elevation 8 IZ /. 6 I
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines ()
Bottom of System ( )
Final Grade O
Date of installation Permit number 33,F 75'I State plan number
Plumber's signatur License number < S/,h l Date 3 /ago/ eo
Inspector
Complete plot plan
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