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AS BUILT SANITARY SYSTEM PEPORT
OWNER ,646- ~1iJj S~~ '1' 0 4' N S H I P ~~4 t~ S E C 13~ N- RW
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
I di at N r h rr< w
_ U1 L
BENCHMARK: (Permanent reference Point) Describe: 44-j/,'~ Ix-Iii
Elevation of vertical reference point:_Q.0_ -Slope at site:
SEPTIC TANK: Manufacturer: ,,y~ Liquid Capacity:-'ma0 /
Number of rings on cover 'Dank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
-
Number of gal. pump set for a cycle- ----gallons; Total capacity of
distribution lines gallon: size of pump _ head;
gallon per minute ; horsepower ;brand name of pump
and model number- ;
Type of warning device _
HOLDING TANK: Manufacturer Number of g, llons_
Elevation of manhole cover _ _ ;
Type of warning device
SEEPAGE PIT SIZE; Number of pits _ feet diameter
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet. ,
SEEPAGE BED SIZE: number of lines widtYi --length~_tile depth
SEEPAGE TRENCH: width length-
PERCOLA`T'ION RATE , AREA REQUIRED' AREA AS BUILT
INSPEC'T'OR
DATED PLUMBER ON JOB (fcc~,~ aJE'et-
LICENSE NUMBER
l
EPAHTWENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
_ABOR & IJUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
'.e. BOX 7969 BUREAU OF PLUMBING
MADISON, Will 53707
CONVENTIONAL ❑ALTERNATIVE Stet. Plan I.D. Numb.,:
I ll .aupnedl
El Holding Tank El In-Ground Pressure 1:1 Mound
NAME OF PERMIT HOLDER: ADDRESS Of PERMIT HOLDER: INSPECTION DATE:
Dennis Brotzler R. R. 2 New Richmond WI -3 ^'jp
"BENCH MARK IP.rman.nt refer..... poem) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
;NE NE, Section 21, T31N-R18W, Star Prairie Township
Name of Plumber. MP/MPRSW No.. Couty: Sanitary Permit Number:
Cal Powers 1563 iS"t .Croix 34822
';EPTIC TANK/HOLDING TANK:
UTLET ELE WARNING LA LOCKING COVE
MANUFACTURER LIQUID APAC)ZY TANK INLET ELEV TAIY
PF VID ED. PR~OV,ID °
t, L] S N O Ld 1^ES NO
BEDDING VENT DVENT MATL. HIGH WA JIN
TER OF ROAD: PROPERTY WELL. aUIII,,II}}NNG: VENT TO FRESH
j- ALARM FEET FROM LIN AIR INLET
DYES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER JBEDDING FL CAPACITY PUMP MODEL PUMP/SIPHON MA DRER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AN CONTROLS OPERATIONAL 1:5~R F PROPERTY WELL BUILDING V N
(DIFFERENCE BETWEEN M LINE AIR INLET
PUMP ON AND OFF) ❑YES UNO A FT-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ENGTH IDIAME TER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FO CE
the soil is dry enough to continue.) M IN
CONVENTIONAL SYSTEM: 4 4
WIDTH LENGTH N DISTR PIPE SPAC INSIDE DIA PI 5 LIQUID
BED/TRENCH THENCHrs M
A E AL PIT DEPTH
DIMENSIONS 12- 1
U,v
.:GR V L DEPTH FILL DEPTH IDIST I I f DISTR PIPE IS I A IAL DIsT NUMBER OF
FER~ ELL BUILDING. V NT TO FRESH
BE LOW PIPES ABUV OyEH EL V NLE I E V END - IPES FEET FROM L AIR INLET
r ~ `~~-~j NEAREST
VIOU SYSTEM:
i
Mound site plowed perpendicular to slope Check the texture of the fill ja
or PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound sys to make c it ON REVER
SE SIDE. SHOW ELEVA-
meets the ri for medi sTIONS MEASURED.
❑YES FIND
SOIL COVER TEXTURE PER ANENT MAHKE IS OBSERVATION WYE LLS
❑YES FIND
DEPTH OVER TRENC HlBEO DEPTH OVER TR N H/ ED DEPT F T PSOI Z 14Y EEDED MULCHED
ENTER DGES
f S ❑YES FIND ❑ ❑YES ❑NO ❑YES ❑NO P4,Zf
PRESSURIZED DISTRIBUTION SYSTEM: /
r _
WIDTH LENGTH NO. OF ; LATE A PACING rAVEL DEPT BELO PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCH
DIMENSIONS 711,
OLO PUM MANIFOLD/
ELEV ELEV Of A 1oiSTR PIPE MANYOLD MA EHIAL NO61 STH DISTR. 1 DISTHIBUIION PIPE MATERIAL Is MAHKING
PIP
ELEVATION AND ELE V LS DIA
DISTRIBUTION
INFORMATION HOLE SI/F HOLE SPACIN( DIAL (IHRECII V COVFH MATf HIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES LINO ❑YES ❑NO
`~~OMMENTS: PEHMAN~-N A K OBSERVATION WELLS NUMBER OF PROPERTY WELL: BUILDING
FEET FROM _ LINE
DYES I_INO DYES LINO _ NEAREST-3
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE 1 LE
OILHR SBD 6710 (R. 01/82) _
DEPARTMENT OF APPLICATION
INDUSTRY, FOR SANITARY SAFETY & BUILDINGS
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Ma ling Address:
r -r
Property Location: (,4y,uil.lago-w To ship: County:
% AS T_ Y ' N/R (Or)
Lot N~ber: Blk No.: Subdivi ion Name: Nearest Road, Lake or, Landmar(: State Plan I.D. Nu ber:
i (lf assigned)
TYPE OF BUILDING -F
Number of
El Public* 1:1 Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required. 3
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY G
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
pc_e
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
f' r ; ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
q Private ❑ Joint ❑ Public 1 A141
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: a S' ture: WMPRSW No.: Phone Number:
r
Plumber's Address: Name of Designer:
1 J
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Age60 F e: Date: Sanitary Permit Number:
~ APPROVED
❑ DISAPPROVED
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
Form - `i 'l' C 100
Owner of Property
Location of Property N~ 1-4Section _e~~ T ~l N R/ W
Township 5~e~. I r~u l y < e -
Mailing Address t: ~OA
e~ G 5 ~~a
Subdivision Name
Lot Number
Previous Owner of Property ~Qlrrie7t- ~Syf7/WVJ
Total Size of Parcel ,-~-.7,7
/rC`r~5
Date Parcel Was Created_ ~~7~fvG~1 3r! , f9h~
Are all corners identifiable?__ Yes - No
Include with this application one of the following:
-,-,,.Certified Survey Map
.Deed
.Land Contract, or
.Other Legal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. ~3tle.5y ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
SIGNATURE OF C6kNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
s
DATE SIGNED DATE SIGNED
,STMENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, e DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION:() SECTION: j p TOWNSHIP•*Me4M#=Uan Y: LOTNO.:BLK.NO.]SUBDIVISION NAME:
COUNTY: OWN R'S/BbY-E~ME: MAILING ADDRESS:
► l f3 c 1--r ? ,1 s
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
[*Residence 17 NNew ❑Replace Il t~
RATING: S= Site suitable for system U= Site unsuitable for system P c- 6 C~
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-Fl LLHOLDING~TTA7,IN~K: RECOMMENDED SYSTEM: (optional)
❑S ❑U ®S ❑U ®S ❑U ❑S U ❑S.-L~1u G C, r, v n on
cj-
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE 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- 7l ` j e
i
B- z ? rr, 5- 00 e- > -1 'r31 • 1' yz' 1s,- Z' - s±
B- Ll. 5-~ t'1 d n F'- l / ~i'~ !C'/ /s ` % yZ' s ? • ! s,r
B- N .:33, c~Y)P, ~ c~ I' fI<' r 2_3 2 ~ ,~7 1s 2,7
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER F€S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-~ ^0e S I/ Y
P- 9,71, cot?
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 ELEVATIONS 7. '7
t
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fir. ..,Z_._ e... _ _ j ~ _
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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.
TESTS WERE COMPLETED ON:
NAME (print):
POW
AD S: CERTIFICATION NUMBER: PHONE NUMBER (optional):
_31 '7
CST SI T RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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