HomeMy WebLinkAbout022-1084-95-000 (2)
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REPORT OF,INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitatty Pv'unit/-
State Scpt cl-
I
NAME i ownship S$. Cttoix County
_ Section oe
Location A/I Cc~ _
SEPTIC TANK O&U-3", 4-4~-
Size gattons. Numbers o6 Compan.tmen,tt6
Distance Fnom: Wett it. 12% on greaten 4f-ope it
Bu.itd.ing it. Wet ands ~ •
H.ighwaten it.
DISPOSAL SYSTEM ,
D.iatanee Fnom: Wett at. .12% on gneatetc ztope it.
Bu.itd.ing St. Wettand,6 Ft.
• H.ighwaten it.
FIELD DIMENSIONS:
Width o6 tneneh it. Depth o6 rock below t.ite in.
Length o6 each tine it. Depth o6 rock oven tite .in.
Number o6 tinez Depth of ,tile below gttade in.
To.tat .length o6 tines 6t. Stope o6 trench in pen 100 it.
Di, stance between tines it. Depth to b edno ck it.
Totat absonbt.ion area 6t2 Depth to g toundwaten it.
2
en on Stttaw
Requined area it Type oi Coven: Pap-
PIT DIMENSIONS:
Number o6 pits Gnavet around pit.5 yeas no
Outside d,i..ametetc it. Depth below .intet it.
2
Total abzonbt.ion area it A
Attea nequitted 62
INSPECTED By TITLE
APPROVED ,DATE 197
REJECTED DATE 197.
State and County State Permit #c"
67 Permit Application County Permit # 4A), '
PLB
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♦ for Private Domestic Sewage Systems County _
r
*DENOTES STATE 'APPROVAL REQUIRED
Date Approval Received from State if Required - State Plan I.D. # _
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: Y4 51 Section ,Z T.22& N, 13,11' E (o W Lot# City _
Subdivision Name, nearest road, lake or landmark Blk# - Village
Township
C TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance _
Single family y~ Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher ,✓`YES NO Food Waste Grinder _YES YNO # of Bathrooms Automatic Washer ff YES NO Other (specify)
E. SEPTIC TANK CAPACITY fC)®d Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation ✓ Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) Z 2) .Z 3) Z Total Absorb Area / sq. ft.
New ✓ Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width _ Depth_Tile Depth No. of Trenches
Seepage Bed: Length Width /,Z ' Depth ado' Tile Depth _-ZJ4 No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size T
Percent slope of land Distance from critical slope SZS7-_
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 Tester, /
NAME ii ~l 'rod C.S.T. # 672-19~5- and other information
obtained from F''' j (owner4ti+1ekr).
Plumber's Signatur MPS 66 6~! Phone 2r j _
Plumber's Address 1.14 4AEV
PLAN VIEW: Provide sk t below of system (inglu a direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Space Below r FOR DEPARTMENT ~USSE ~ONLY
Date of Application ! Fj Paid: State 1~'~`--County Date
Permit Issued (date) -Issuing Agent Name 62 4 X19 A-1
Inspection ' ss No 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 6/1 /76
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICESV
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH l
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS:
LOCATION: ~~XJ J'/C Section TZ N, R 1° E (orE -Township or Municipality K I ty K,Aiy
Lot No. Block No. County ~T-
I I ~ IZ I Subdivision Name
Owner's Name:
Mailing Address: 111 CAR-C' D(-_ h/`tNt E L_ ITAL)CIZ P, ZI./ ER rAL-L-f y✓ I S •
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT p
DATES OBSERVATIONS MADE: SOIL BORINGS -7 ° 2 3- "7r PERCOLATION TESTS 7-- 03 ' -78
SOIL MAPSHEET__ _ SOIL TYPE y-'_4_C✓~ J-14AV ~Y LCD ~1
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
I
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346 SCE SUIL i3olzE Dti?~ I N o O " + 2
SN N Py So t L-
it--Z 3~ NO 6
S a Z
10
Sd N uv sa „
1_3 3 10
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
F UMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
I~ 2 -7Z 7 Z" c D S P.
f Z 73 11 I. S 16 " ; 4 N\C 0 s 0.
€
4 72 M E~ S~
L _T
j Z~ 72
IVZ E D V
7 4- ' " TS fa 9 M D U '
P-AN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption are'i
needed for building type and occupancy. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) LA iLC N C E M iJ1Zp ri ~J Certification No.'s
Address IZ R x 3 I? 1 V
Name of installer if known
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~COPY A -LOCAL ALI'i'e=17Y
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