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AS BUILT SANITARY SYSTi%'M RLI'010*
UWNI:It IFS TO WNSlll1'd ~i24- 1q -IC~w
1 s',/ ~1
AUUKL:SS ST, CttU1X I,uUN'1'Y , WI St:UNS IN
SUBDIVISION LU'1 LOT Sl"LL:
V LAN V 11: W
DiaLUnces and dituenuiund Lo meet re~lulrc ueut ul 1163
1:;VtMIH1NG WlTlilN too F1.11-1, OF Sy.;TFM
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1 d1 e e c►t't At-row
SC LIB
BENCHMARK: (Panuanant rafarence Pulnt) bertcribe : r f /''!~~-'r' tea
Llevation of vertical,..reference pulr►L. 1 O tupc aL 6i Lc
SEPTIC TANK. Munufacturer _L,_" Lr(Iuld Cu1),1 L t y /6"oo j ~ -
Dlumber or ringa on cover 'j , / 1fx111t it ailho e Cuvu [ ( Icvii I l
Tank Inlet LLavaLion 1Q~ Tu„k ouL lct I t.,vut 14),, '
--1D Z_LQ_
PUMP CHAMBER
MarlufaC tuner : Nwiibc i ul },<l l l u,,:.
Number of gal. pump k►at Eor a cyc7e_ l;rl Iul,s . t ut,ll ~1 y ()F
diutributiun lima 1;ultoll, aitc a putup
gallon per tutnuta horuopowe.r T bl im(„ckiliC 0I I)Luu(J
and utlo d u 1 n untb a r
'T'ype of warning davice
HOLDING TANK: Munulacturer
h levaLion of tnurthole cuvar
~ w lt
aLE11, ;E '?IT S1Llg davice
E Nuulhcr o( I:: , 11~~t (ll,uuc t 4~ ,
fut- liquid ticepaec I,x t '%1 : lit l ~1v,,l~ L011
cif 1011[ Of seupmKC pi-t- eY0vut ~ utl
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t wi+ I I
I;h SIZE;. m-auber of lluct) l ~tc
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BU!LDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS Q DIVISION
P.O. BOX 7969 N BUREAU OF PLUMBING
MADISON, WI 53707
~ICONVENTIONAL ❑ALTERNATIVE StatePlanl.D.Number:
El Holding Tank ❑ In-Ground Pressure El Moun (if assigned)
d
NAME OF PERMIT HOLDER. ADDRESS\OF PERMIT HOLDER: INSPECTION DATE.
i - r 1 i 1
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PT. ELEV
it "PI-IRS- 12 Nar• of PlumbeNo. County Samtary Permit Number:
ti J n ,
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPAC ITY. TANII~ INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING VE
PR VIDD. PROVID
;C10 _0 101-7,61 C IES ONO Y 0-
J VENT DIA.. VENT MAT L. HIAM ER NUMBER OF ROAD. PROPERTY E L j.UH_DI.1G,
BEDDING :
EI VENT TO FRESH
AAIR INLETFEET ROM /
YES NO / O NEAREST-----30-
CHAMBER:
DOSING.
MANUFACTURER BEDDING. LiV 1. P L JIUMPiSIPHON MANUF ACTUREH. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED'.
OYES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: P PAN O ROLSOPERATIONAL NUMBER OF PROPERTY WFLL BUILDING (VENT TO FRESH.
(DIFFERENCE BETWEEN FEET FROM I EAE AIR INLET
PUMP ON AND OFF) YES EINO NEAREST 30.
SOIL ABSORPTION SYSTEM. Chec e so' Istur at e depth of plowing Fw,sil, Ar.,l TFR MATERIAL AND MARKING
or excavation. (If soil can be rolled into a were, constru tion shall cease until FORCE
the soil is dry enouqh to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH IT LENGTH TRENF DISTR PIPE sPACINC, covER INSIDE DIA Plrs uoulD
DIMENSIONS 2.181 L PIT DEPTH(,RAVFI FPTII FI LITDEPTH JDIST PIPE DIDISTR.PIPE MATERIALN
MBER OF PROPERTY LBUILDINGVENT TO FRESI,
[3EIPFABOVE COVER ELEV INLFf ELEV END FEET FROM LIN AIR INLET1n L NEAREST-~,
MOUND SYSTEM: to 7
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound s s s to make certain that it ON REVERSE SIDE. SHOW ELEVA-
mee the r e medium sand. TIONS MEASURED.
OYES NO
SOIL COVER. TEXTURE PERMANENT MARKERS. OBSERVATION WELLS
EYES ONO OYES ONO
DEPTH OVER THE NCH BED DEPTH OVER 7H BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTFR EDGES OYES ONO
DYES ONO OYES ENO
PRESSURIZED DISTRIBUTION SYSTEM: _
WIDTH LENGTH NO.OF LATERAL SP ING. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DI R PIPE ANIF MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
EI Fv. ELEV. DIA. EV. PIPES DIA.:
ELEVATION AND
DISTRIBUTION
ROLL SIZE HOLE SPACING D i ED O FCTL COVER MATERIA L VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
YE NO OYES ONO
COMMENTS PERMANENT RKERS-. OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUILDING:
FEET FROM LINE
~Y•. OYES ONO OYES ONO _ NEAREST--_
7 8)
e.~tv
L
Sketch System on Retain-in county'file for audit.
Reverse Side. '
SIGNATURE. r TITLE
DILHRSBD67101R.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'/z 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. The owners copy or a legible reproduction of the soil test report must be
included.
r 71
Property Owner: Mailling Address.
Pro erty Location: :k &ge or To' nship: County: _
'/a /QS iT__? NiR (or) W
Lot Number: Blk o.: Sub ivision Namer Nearest Road, Lake pr Landmark: State Plan I.D. Number:
/ (If assigned)
TYPE OF BUILDI G
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY ~9/ rf
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER::.
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): 3 New ❑ Replacement ❑ Experimental EY Seepage Bed ❑ Seepage Pit
° J/ ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: ______JCwner's Name as Lis ed on Soil Test Report (If other than present owner):
leN Private ❑ Joint ❑Public /
i
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
JON.
Name,.of Plumber: Signa re: MP/MPRSW No.: Phone Numbe
(A-
Plumbers` Address: f~ Name of Designer:
ti
COUNTY/DEPARTMENT USE ONLY
'jig ature of Issuing Agent- Fee: Date: Sanitary Permit Number:
_ ❑ APPROVED
❑ DISAPPROVED J
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-
stsilation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DiLHR-SBD-6398 (N.03/81)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOk BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON W 53707
LOCATION: SECTION: TOWNSHIP/ fet1TALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNER'S BUYER'S NAME: mAIL1NG ADDRESS: -
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE R TONS: ER A ION TESTS:
rKIResidence ! New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system 1 7
CONVENTIONAL: MOUND: IN-GROUND-PRES''SIIURE:SYSTEM-IN-FILLHOLDfNG TANK:RECOMM N ED SYSTEM:(optional)
S S ~U S ~V [:]S ~J Lef~j
%
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL
If any portion of the lot is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 7
T
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
F/ '
13-
SL -zz i
r'
~1 i .1 a-_Jis ~C
r) nur
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PERINCH
P / r i S1/ l
P- / 3 S .
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 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 slop.
SYSTEM ELEVATION
I I
/7
® 1 Inc : /_sr
t~
,l%9r fir.
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IN
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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 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:
ADDRE - J I CERTIFICATION NUMBER: PHONE NUMBER optional):
CST S ATURE:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
&,H,R-SBD-6395 (N. 03/81)
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