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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ;ay>,;: SEC : z
44T Z9N-RI;W
ADDRESS PIERCE COUNTY, WISCONSIN
SUBDIVISION - - LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
YTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: C`t Slope at site:
SEPTIC TANK: Manufacturer: a"> Liquid Capacity:
Number of rings on cover Tank manhole cover elevation: -'•--F-,
_ Tank Inlet Elevation: '7j' - Tank Outlet Elevation PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity--of--
distribution lines gallon: size o pump head;
gallon per minute horsepower ran name of pump
and model number
Typo of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
't'ype of warning device
SFI: 'J'ADE PIT SIZE: --Num er o t pits feet diameter
Feet liquid depth seepage pit in eft pipe-elevation
hottom of seepage pit e evation feet. -1
SI,EI AGE BED SI7.E. number cf lines widthleogth the depth
SI;E11AGE TRENCH: width length
I'EfZCOLATTON RATE 0~ z.3, - REA REQUIRED , j AREA AS BUILT a t ,
ll TI']p 1 PLUMBER ON J R
P w
State and County State Permit #
B 67 v Permit Application County Permit #
- for Private Domestic Sewage Systems County '
`DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY / Mailing Address:
(
_jlrt bt`' l e
B. LOCATION: N4, '/;NC Section, Tr N, R_Z.L E (or) ' Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial "Other (specify) *Variance
Single family Duplex No. of Bedrooms > No. of Persons
D. SEPTIC TANK CAPACITY 0t' Total gallons No. of tanks I
HOLDING TANK CAPACITY -Total gallons No. o tanks
i
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation 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 sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft.--,Width Depth Tile depth (top) No. of Trenches
Seepage Bed: A Length- 3 5 ' Width AF Depth 3e " Tile depth (top) No. of Lines --2
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land c Distance from critical slope 6'
WATER SUPPLY: PrivateV 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 Certjf`o Soil Tester,
NAME ILA, C.S.T. # and other information
obtained from t P1^ (owner/builder).
Phone #
Plumber's Signature, MP/MPRSW# ~I
Plumber's Address 0 ) ° C
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.
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State { County D.t f J~~
e
Permit Issued ~
fREteeted (date) Issuing Agent Name ~t;tAt (4. ~ (i-t ~s>
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
DEPARTMENT OF SANITARY PERMIT SAFTY & BUILDING
INDUSTRY, • TRANSFER FORM DIVISION
LABOR AND P.O. BOX 7969
ROMAN ~ELATIONS (PLB 67-T) MADISON, WI 53707
SANITARY PERMIT NUMBER: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
PROPERTY LOCATION: CITY, VILLAGE OR TOWNSHIP: COUNTY:
'/a '/4 S T N,R E (or) W
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK:
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
ADDRESS: PHONE NUMBER: ADDRESS:
BUILDING USE (IF CHANGED):
NUMBER OF
❑ Public* ❑ Variance ❑ Other (specify)* BEDROOMS:
❑ 1 or 2 Family *State Approval Required
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has either previously been approved
for this property, or that is shown on the attached revised plans.
PLUMBER'S SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGED):
PLUMBERS ADDRESS: PREVIOUS PLUMBER'S ADDRESS:
MP/MPRSW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER: PHONE NUMBER:
SIGNATURE OF ISSUING AGENT: DATE APPROVED DISTRIBUTION: Canary-County
White - Bureau of Plumbing
_ Pink -Owner
DI LHR-SBD-6399 (N.03/81) Goldenrod - Plumber