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AS BU1 I ,T SAN I TARP SYS'1 L M }tl:l'(li~'i
OWNER TOWNS1-11-P SEC. - I' ,-23 N-R W
_j S'1'. CROIX COUNTY, WISCONSIN
ADDRESS
~ f
01 L
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
C~
%s.15 ~E
i
INDICA'T'E NORTH ARROW
s
BENCHMARJ.: Describe. the vertical reference point used
Elevation of vertical reference point: lee. tie' - Proposed slope at site:
SEPTIC T-NK: Manufacturer: ~ lf~/ o Liquid Capacity: /0r Z-, ~;;_I_1 =
Numbi.r of rings used: Tank manhole cover elevation: r~
Tank Inlet Elevation: Tank Outlet Elevation:
Number of fret from nearest Road: Front Side,o Rear, O feet
From nearest property liue Front, Side,0Rear,0feet
Number of feet Er-oiJ: we-1.i building: -,;-I_
(Include this int:ormat_i.on of the ~ibove I)LOL plan)( 2 reference dimensions to septic tank)
1
PUMP CHAMBER
Manufacturer: Liquid Capacit y:
Pwnp Model : _ Pnnip/ Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch ulevation: _ Gallons per cycle:
J 1
Alarm Mi_inufacturer: Alarm Switch Type:
Number of feet from nearest property line: Frout, ~~Side, r~Rear,~} Ft.
Number of feet from well:
Number of feel from bui-fdi.ng:
(Include distances on plot plan).
,,'011. ABS0RBTI.0N SYSTEM
Bed: 'french:
Width:,_ Length; Number of Links: Area Built:
Fill depth to top of pipe:
Number of feet trout nearest property line: Front, aide, Rear,0Ft
Numl)er 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 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? (Ch,_ck one).
HOLDING TANK
Manufacturer: _ Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nuarest property line: Front, 0 Side, a Rear, ~Ft. _
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm N.anufaccurer:
Inspector:
D.ite.d: Plumber on job: _
License Number:
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
L3CONVENTIONAL ❑ALTERNATIVE StatePlan lD Number:
If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Ray Donatell River Falls, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV..
NE NE, Section 18, T28N-R19W, Lot #1, Town of Troy
Name of Plumber. MP/MPRSW No.. County Sanitary Perm[ Number.
Henry Nechville 3258 St. Croix 43723
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. IWAG LABEL LOCK GC VER
P EDPRO
( ❑NO ❑NO
BEDDING: VENT CIA VENT MAT L. HIGH WAT R NUMBER OF ROAD: PROPERTY WELL. BUILDING. JVSM . N FEET FROM l~L A.a'
❑YES NO Y S O NEAREST DOSING CHAMBER:
MANUFACTURER 7INGS
LIQU
ID CAPACITY PU ODEL PUMP/S ON MNUFACTURER WARING LABEL LOCKING COVER
PROVIDEDPROVIDEDONO 1;41 1 ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AN C N OIL R TIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) Y ❑NO NEAREST 10
SOIL ABSORPTION SYSTEM. Check the soil moisture at tP6 de of plo ing ILFN(;TII DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction sh II cease ntil FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE CIA #PITS LIQUID
BED/TRENCH THE ES ERIA PIT DEPTH
DIMENSIONS f ~
G; 3-'
I I'S
G R A V F L DEPTH FILL DEPTH JOISTH. PIPF DISTR PIPE DISTR. PIPE MATERIAL NO. R NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
BE LOW PIPES ABOVEC VER ELE V. INLE_t ELEV. EN/D _ PIPE ~LIN`E: AI E
~p C~.J Z.'I G I Z FEET FROM J . ( I~ 7~
NEAREST-► '
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the textur of t e fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems o m ke certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criterI for /edium sand. TIONS MEASU D.
❑YES ❑NO /
SOIL COVER TEXTURE PERMANENT, ARKER OBSERVATION WELLS
OYES O ❑YES ❑ NO
DEPTH OVER TRENCH:'BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED EE D MULCHED
CENTER EDG ES.
DYES ❑N DYES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATE AL SPACIN GRAVEL DEPTH BE W PIPF. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD STR. PIPE ;MAN IFOL 'M ATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.. DIA. LEV. PIPES DIA.:
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED C ECTLV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
ES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROP ERTV JWELL: IBUILDING.
I -2- 5 7 FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
~r lt'L' cy (Jt? CQ~ 0 S '7. ~~<r I
Sketch System on ' ;ounty file for audit.
Reverse Side.
SIGNATURE TITLE.
DILHR SBD 6710 (R. 01/82)
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
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'/2 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: Mailing Address:
/1 cz c Ca 1,
Property ocation: City, Village ownshi County:
/gS /T ?N /R c' E (o W
x
Lot Number: BlSubdivision Name: Neare Road, Lake or Landmark State Plan I.D. Number:
A*WW
41114 (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
Q~1 or 2 Family *State Approval Required. -3
TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY /LYt" a j A ~ 7/
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental RT-Seepage Bed ❑ Seepage Pit
~~j~ 7) ~ii ❑ Alternative (specify) ❑ Seepage Trench
Watteer SOwner's Name as Listed on Soil Test Report (If other than present owner):
L~ ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: / Signature: / MP fdIFRSW No.: Phone Number:
Plumber's Ad ess: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signa ure of Issuing Agent: Fge: Date: APPROVED Sanitary Permit Number:
fX-~ f 7 ❑ y
• / ~r " ❑ DISAPPROVED 2aG
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 - S T C 100
Owner of Property_
.Location of Property Z-_4 4, Section T ~?G N RAW
Township
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property
T
Total Size of Parcel ~i
Date Parcel Was Created 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 reco ded in the Office of the
County Register of Deeds as Document No. ; 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 duy~recorded in the Office
of the County Register of Deeds, as Document No.
SIGNAT RE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUST5Y, DIVISION
P.O. BOX 76
LaBOa AND PERCOLATION TESTS (115) MADIS
ON WI 53707
HUM:,N RELATIONS
(H63.0911) & Chapter 145.045)
LOCATION: SECTION. OWNSHIP/MUNICIPALITY: LOT NO.: BLK. SUBD VISION NAME:
IVEj5P/a 13 /T99N/11/y E for T ~ 7xev 'V, COUNTY- OWN R'S/BUYER'S NAME: AILING ADDRESS:
~a /:7
USE DATES O EEVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
Residence / G 'C~ll New ❑ Replace
-2 3
q~1U15 [ c'~/
RATING: S= Site suitable for system U= Site unsuitable for system
CONVEcNTIONAL: MO NcD: '1 IN-GROUND-PRES'SIURE: SYSTEcM-IN-FILLHOLDIcNG TANK: RECOMMENDED SYSTEM: ptional)
VNJ L/
If Percolation Tests are NOT required DESIGN RATE: I If an
any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: In ,j
PROFILE DESCRIPTIONS
Aec. f
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ML ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED/ (SEE ABBRV.. ON BACK.)
I ~lG In /~C
r/c7' !31 $I~ ) ..67' 131 SIel / ( ,f-f 5
B- / 91, 73 cIL, S / q.5" (3n sc 1. s$' an r l a..5-' 6n r-s.
i -75-- 131 s t l i i. Y,3C 8 n L, rya-' 6A 1 S J 4 75" iz 9 r 15~
B c~. U 1. 7. r 7 K 0' 3,17 r v~ r
7
7~ ll 7B- 15 Y. C4n r S,
i .75- ' 13 131 s. % A walaw 83 8
B-5- 7~ l/ 7 5,. S / r5-S3~13/5i1J t F'13 15171 •(o7i 4. "BrI
83" 6n 3-3 B n v _y
B-
c1 PERCOLATION TESTS
e c.
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER Lat*teg AFTERSWELLING INTERVAL-MIN. PERIOD! PERIOD2 PERIOD3 PER INCH
P_ j C 5-i'16 l
P_ '-2 AM xr
P_ 3.
P-
P- 5-
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. Elev. - 100, '
SYSTEM ELEVATION ele v. P-1 = f
p-a, 87.3
3
S
P- o 07
7 7
4, F-3
~a i,/ 7' 11 \I
~~s.~7 174S-' P-a- ~
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l qo.5
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SCi~Lt.l•-yL~~=f
Corner
j~ nub' to sail
0 :E::::76
AI > 76. 6
---~1~~
Al. 6- o G-L Ro oeD ig~re~, F
I, the undersigned, Hereby certify that the soil tem'reported on this form were made by me in accord with-the procedures n methods-specifie-din the Wiscunttr -
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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
;CST Sh\AT~.JRE:
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