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AS BUILT SANITARY SYSTEM REPORT
t1WNT:R C TOWNSHIP SEC./2_`1Z?N-10/W
ST. CROIX COUNTY, WISCONSIN.
lilVl`; :L UN LOT LOT S
PLAN VIEW
Iiinces and (liluerisions to meet re(luircuicnt-,; ul_ H63
'HUW. L;VL1lYTIiIN(: WITHIN 100 1'1:1.:T O Sy"11,11
i"s Pe A ~
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I~L;NC1iMARK: (Permanent reference Point) Describe: o ~/e~~ L
_
1: Levation of vertical reference point;_ A20, 6 Slope at site:--/w
:4,1 TLC TANK; Manufacturer: Liquid Capacity: %DOO
Number of rinks on cover : Tank rnrrnliole cover elcvati.un 97•21
'
Tank Inlet Elevation. 5r0~ Tank Outlet Elevation_1Z'---
rUMP CHAMBER
I,~nuttrcturt.r Number of gallons
J ~ra1]~r of )!,at. ^puuip set fur it cycle -gallons, total capac i.ty u
i i t_ri.bution Lilies ga I tulI size oI Dump - head;
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DEPARTI'4ENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS v DIVISION
P.O.J3OX 7969 BUREAU OF PLUMBING
MADISON, WI 53707 ❑ALTERNATIVE State Plan IID. NumbP
I
fl~ICONVENTICINAL \ (If assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound n
NAME OF PERMIT HOLDER. JASS OF PERMIT HOLDER INSPECTION DATE.
f
BENCH MARK (P anent ref. e ce point) D ORIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
Name of Plumber. JMPIMPRSW No.. Coun[y Sanitary Permit Number.
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIDUID CAPACITY. TANK INLET ELEV./ TANK OUTLET ELEV. WG LABEL LOCKI C
1 P ED PRO E
ES LINO ES NO
BEDDING. JV . VENT MAIL. HIGH WATFyR NUMBER OF. ROAD. PROPERT WELL BUILDING IVENT TO FR SH
ALARM FEET FROM _ LI~N' /IF, NLEr
❑YES NO 1:1 NEAREST ~CZ 1~ f ~G PY
DOSING HAMBER: _
MANUFACTURER BEDDING. LIQUID CAFACITY PUMP MODEL PU MPiSIPH ON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES LINO I ❑YES LINO ❑YES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF rTOPERTV jW11L BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES LINO NEAREST!
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ~vall~ I)InrnfIER [MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until L MAtN
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM: _
11ID1 H. LE GTH JNO01 DISTR. PIPE SPACING. COVER INSIUE DIA zPITS LIDUID
BED/TRENCH % TRENCHES. MATERIAL PIT DEPTH.
DIMENSIONS
GHl~I FL D: PTII FILL DEPTH [4ST11 PIPF DISTR. PIPE DISTR_PIPE MA' ERIAL. NO. DISTH NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH
eh f]W PIPf 5 ABOVE COVER ELEV INLET ELEIY_ END. PIPES . LINE AIR INLET!
FEET FROM
NEAREST--~~
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES NO
SOIL .`OVER. TEXTURE PERMANENT MARKER S. OBSERVATION WELLS.
fF( ❑YES LINO ❑YES LINO
DEPTH OF TOPSOIL./ EEDED MULCHED
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED
CFNI FR EDGES /
BYES LINO S❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM: r~
WIDTH. LENGTH NO. OP L ERAL SP CING. GRAVEL-DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR'PIPE MANIFOLD MATERIAL. NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV. ELEV. DIA, ELEVPIPES' DIA.:
ELEVATION AND i
DISTRIBUTION
h{OI_E SIZE HO SPACING DRIL CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANTS
_ ❑YES LINO ❑YES LINO
COMMENTS: PERMANENT MARKERS-. - OBSERVATION WELLS: NUMBER OF ,PROPERTY WELL: BUILDING:
FEET FROM uNE.
❑YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on Beta in ni file for audit.
Reverse Side.
,r SIG NATO r TITLE. `.r
DILHR SBD 6710 (R. 01/82)
• x,40
PLB 6-7 State and County State Permit #
w Permit Application County Permit #
for Private Domestic Sewage Systems County ST GR o r K
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address: 9
A G l.L R Aft ~.ql w r ~1 t W r S
B. LOCATION: /Vj' % E Section 13 , T AC/N, R V (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# f7~-~AY 6 Village
Township f AMr»o.✓q(
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X Duplex No. of Bedrooms I No. of Persons
D. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks OA-) C!,
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement X
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
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
by the Certified oil Tester, 1 j
and other information
NAME ~c l C.S.T. # 0
obtained from ~tJ e AL--,7 (owner/builder).
Plumber's Signat e MP/MPRSW# 1Y11'J'.9 Phone
Plumber's Address L L.-) i
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State It j_ County Date A, ( ~
Permit Issue ed (date) Issuing Agent Name U
L 4-
Inspection Yes No State 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) Revised Date 7/1/78
DUS DEPARTMENT OF, REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUS
NTRY,
LABOR AND P.O. BOX 7969
HUMAN RELATIONS' J PERCOLATION TESTS 115) MADISON, DIVISION
WI 53707
3707
i (H63.090) & Chapter 145.045)
LOCA ON
: SECTION: TOWNSHIP/MU ~C:JPALIT
Y: LOT NO.: BLK. NO.: SUBDIVISION NAME
1/4
COUNTY: OWNER'S BUYER'S NAME: ~~11 MAILING ADDRESS:
T• exo1X " L~_ /4 CC l~6 RAF'
q 1 4 1t~~, ~ (was
USE DATES OBSERVATIONS MADE
~ppff NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILEDESCRIPTIONS: PERCOLATION TESTS:
X Residence .1 ENew Replace /6 ~'fic ~.~K-®NLy l
RATING: S= Site suitable for system U= Site unsuitable for system ~
ONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTIHOLDING TANK: RECOMMENDED SYSTEM:loptional)
~ S ❑u ❑ S ❑u ❑ S ❑u o u EIS ❑u
If Per
colation Tests are NOT required DESIGN RATE: [Floodplain, any portion of the tested area is in the
under s.H63.09(5)(b1, indicate: indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST. HIGHE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
i
j
;3,q .51 ~ r s SCI o .7D(/
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERT 3 PER INCH
P -
P-44a) _j
P-
P- . /q c E?,
P- Ao.
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 go A
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as a
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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• Visconsin
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:
4 4-
ADDRESS. - - _
CERTIFICATION
NUMBER: PHLNr Ji!f✓IBER pucnall:
ST SI TURE:
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