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HomeMy WebLinkAbout020-1104-40-000 o d .~1 3 ' (D v n o at c r: U) 0= N z v a fn c A N . 3 N O O y' d IV O (D O O CD N co N O O (D Di Co (D CT R Z d = N CO L O `A\ O- A W A y f~ co N 3 7 O A "S 1 N j N N (D0 O (D (D c) C) , CD cn co O O OD c (D 7 n D) N o O (T V N (Ji 3 _ N O ra in 7 fA N O C (~I 4 (D P- (D CD 0 a (D Oo (D m 1 O A W O_ O O N V N N 3 rn cn a O O O (D 3: A W A (D W CL d n r v> l\ CD IWO IC03 10, U) cn <1 A~ tr n fA !n N C CL Q O 0 _0 m CD N O E. -0 po r', ('D Q \ ` y N O 0 \ (D ° °N°o o zco z o o . -7 o. ~ tr ~1 r\ N N N 0 fn~11 • O O ~ .w O (n !V C) CD (n cn (OIt O O .Z7 "O C CD 0) - FT CD (D CD --j cp 3 w~ " r• ~ C a z o (n -4 a co m \ a z a° O' 3 a O r: N Z W F Q CL o' i v c z O. O U) ~ ~ I o II a ti .J O I,I Oo O Q (D ryq Cry C) CD C) CL AS BUILT SANITARY SYSTEM REPORT QWNER e _ a - >rR TOWNSHIP SEC . T N-R W ADDRESS CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE . PLAN VIEW Distances and dimensions to meet requirements of H63 'HQW FXEWTHING WITHIN 100 FEET OF SYSTEM 7~ a Z~a t ~ - I di a e o th A ro - - I S C L . 1 e BENCHMARK: (Permanent reference Point) Describe: A 11evation of vertical reference point: y :,r Slope at site: ` r SEPTIC TANK: Manufacturer: fG/ ?tct.~« Liquid Capacity: ~tumber of rings on cover Tank manhole cover elevation: - y Tank Inlet Elevation: Tank Outlet Elevation: Tank Manufacturer: Number of gallons ~ j,.Number of gal. pump set or a cycle _ gallons; total capacity o4 . distribution lines gallon: size of pump head; gallon per minute horsepower ran name of pump and model number ; Type of warning device MOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device PAGE PIT SIZE: dumber o pits Feet diameter feet liquid d4pt seepage pit inlet pipe-elevation bottom of seepage pit e: evation feet. depth SEEPAGE BED SIZE: number of lines wie th length-4) SEEPAGE TRENCH: width` length PERCOLATION RATE SEA RE UI ED AREA AS BUILT " INSPECTOR DATED PLUMBER ON JOB _ LICENSE NUMBER -r^~ ! • State and County State Permit #y~ B'67 Permit Application County Perm jt for Private Domestic Sewage Systems County 4?, *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: r - B. LOCATION: Section T N, JIMr) e.1/U' Lot# City Subd~vision Name, nearest road, lake or landmark Blk# Village Township C./1G C. PE F OCCUPANCY: *Commercial *Industrial *)ther (specify) *Variance Single family Duplex No. of Bedrooms Q No. of Persons_ D. SEPTIC TANK CAPACITY Total gallons No. of tanks l HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation 2. Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area a sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth-Tile depth (top) No. of Trenches Seepage Bed:_ 4 Length Width Depth l p_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 t 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 Soil Testey„_..__. NAME - C.S.T. # and other information obtained from "f • (owner/builder). r f Plumber's Signature_ , .MP/MPRSW# . Phoner!"tj - rte' Plumber's Address 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. 3 i 3 3 e I 3 j i E - 3 , - m Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE NLY Date of Application Fees Paid: State D G&ttnty Date - Permit Issued/ (date) Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (wh t 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 DEP, qTMEN-f OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS L;, NI,`MAN I►ELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE State Planl.D Number. (if assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound N OF PERMIT HOLD ADDRESS OF PERMIT HOLDER: INSPECTION DATE 2- B H :A( ermanent reference point) DESCRIBE IF DIFFERENT FROM PLANRECST REFPTELEVName f Pr_ P/MPRSW a County Sam2tary Permit Number'. d r a SEPTIC TANK/HOLDING TANK: G . 2 MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKIN COV PRO DEDES ❑NO PROVI ED 5 N _ S W BEDDING: VENT DIA. VENT MATL. HIGH WATE NUMBER OF ROAD: 1PROPERTY WELL BUIL ING. ~VE T ESH ALARM FEET FROM LINE' AIR N E YES ❑ NO ❑ ' 64O NEAREST 7 t _~j W DOSING CHAMBER: _ MANUFACTURER BEDDING. LIQUID CAPACITY IPUMP~(IDEI PUMP/SIPHON MANUFACTURER WARNING LA EL LOCKING COVER PROVIDED'. PROVIDED'. ❑YES ❑NO ❑YE S ❑NO GALLONS PER CYCLE: PUMP nN CON ROLS`OPERATIO AL, NUMBER OF PROPERTY W LL NG VENT TO FRESH (DIFFERENCE BETWEEN / FEET FROM NE AIR INLET PUMP ON AND OFF) ❑Y' ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture the de of plowing JI F N: TI, [)1~W1FTER I/TFRV AND KINa or excavation. (If soil can be rolled into a wire, cons'tOuction shall cease until FORCE the soil is dry enough to continue.) / MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA PITS LIQUID BED/TRENCH TRENCHES %Ar AL PIT DEPTH DIMENSIONS GHAVF 1 UFPI II FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. R NUMBER OF PROPERTY WELL BUILDING- VENT TO FRESH j BE (L, VIPT F. ABOVE COVER ELEV "L" ELEV. END'. PIPE LINE O AIR INLET L r~ s7a^ FEET NEAREST--► Y7 / I -IZ MOUND SYSTEM: r Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound stystems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER. TEXTURE PERMANENT MARKERS. OBSERVATION WELLS _ ❑YES ❑NO ❑YES ❑NO DEPTH OVER THE NCHI DEPTH OV ER TRENCH.' BED DEPTH Of TOPSOIL SODDED SEEDED MULCHED CL NT FR EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: _ WIDTH. LENGTH NO. OF LATERALSPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRE)IvCHES DIMENSIONS > Z ^ MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. r/yjA ELEV. PIPES DIA.: ELEVATION AND . DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED. CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS /LYL ES,/" ❑NO ❑YES ❑NO COM _MENTS: PERMANENTMARKE OBSERVATION WELLS: NUMBER OF. `PROPERTY WELL: 1111,11-DING. FEET FROM LINE i❑ YES ❑ NO ❑ YES ❑ NO NEAREST---~H Sketch System on Retai in county file for audit._, Reverse Side. [SIGNATURE. TITLE. DILHR SBD 6710 (R. 01/82) -J f~ ✓ DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS "IN~TR,Y„ DIVISION LABOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 LOCATION: SECTION: TOWNSHIP/ W412A-L- ~ LOT NO.: BILK. NO.: SUBDIVISION NAME: sw_swt/a 1/a sq /TzaN/R 13 E (or v~ soi, _ _ - COUNTY: OWNER'S Bt- } E'S NAME: MAILING ADDRESS: S7 ' CRQ~ ► -I ~ S Li t S \C6'61 ►M C C rt11 }J tC Ue. Zo 7 S~ -'j r'cv LN " lv. 5,51/3 USE DATES OBSERVATIONS MADE ~ NO. BEDRMS]COMPERGIALDESCRIPTION] ?-RUFME DESCRIPTIONS: PERCOLATION TESTS: EgResidence 3 :New ❑Replace S 8 Z S~l l8 Z RATING: S= Site suitable for system U= Site unsuitable for system 00NVENTIONAL: MOUND: JIN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S []U ❑S RU , ®S ❑U [RS ❑U ❑S z' y- Sz' -S j--b If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. If any portion of the lot is in the under s.H63.09(5)(b), indicate: f Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 1 119, BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, C DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. CK. O B- \ 8 91 S 1u ~>L 77 n: 0 B- Z -7 3 S 1 - ? 3 3 ` G S w~ G IDN/NC ~98~ !v B- -78 9~ 1 -7 ~7 C3 -7 `~i ~S W "/6;_ B s ~L7 IV0r`1C 7-7 ' d s B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES A TER SWELLING I TERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH P_~ 3~ Q ' - < E, 6 I If P_ z 3 - y 6 G 6 ~I P- 3 8 1 6 G P- P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the 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 per of land slop. p_ 66 Sol(, SLR ui:~W Gp SYSTEM ELEVATION Tu_nz~ 4-4 cg),t -7- s3 S 3oC~' tJ. \S~ E, „p~oS I: ST St3' F1Lor-t ZatZ-+It-~x.1Fz I ~....WI w fELB) too b ~ Q ST~thcbs 4FJ t H "s" f'ov app s s ~~,ou 3~ / S S\Tma_ x' q S~A~- ,fit =I}>,-XCQT I^lS S1~OWlJ the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative 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: l~-~`~-1vR L " 1 g, 1516z ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): \?bv LLS ot2` ~a t I S-)6 r s-U zs- 32 8 1 CST SIGNATU n DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. o..uq.Sgr)-fi'uc Int. noio ~ g1 M CIi At-)10- AUE . ~ lolt it Z°~o I I N i---~ L.L. SS /r77 ~ I I cz- ~L. 9~ S o 1D E~. 93__5 © o tN-~kJET EL _ 9S Y_ SCA L;-- ~UR l~~ = ZC7' V ' t4 LL S V2dgl MECli A N t c IJ UE . II z°to ( L-- Li ~S I I I rr i I I Q - ~L 9u 5 o p -lo - --1 EL,-9~f- - _-~L-,_93 S o o I I '~_~°~-A C~}~1LvT T1J1Tl P~ L ~ ~ o ~ G r\ L U~~ _ Q ~ WI~S~~' S~`~CTR'►J1~ PF,(~)Fl Lam. S Cry LE S>~MS FILL I S 1`a~31 1`~ E C1-t A ►v l: c ~i vE . S~'.~AvL, 4~N. 55119 ~I ICI ~i S1 S I 1 I II I I I I ! SS I I 13~ J/ s ~ 93 i i I °t-A CAN EST j1J \Tl R L 1 o G L P~OrI L~ \ C~J TL 1 i =