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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP -7;Up y SEC. &_TZr-R2j`W
ADDRESS , ST. CROIX COUNTY, WISCONSIN.
..f
SUBDIVISION LOT o27 LOT SIZE
PLAN VIEW
Distances and-dimensions to ineet requirements of 1-163
Inl- EVERYTHING WITHIN 100 Fl-'E'T OF SYSTE14
° E L
- ST
- - - ,
9 0' _
} 2
- - " - I.
D
4
e~ pt
a I diatty or, th~ Avow
12 74 SCAT
BENCHMARK: (Permanent reference Point) Describe: 0-&RT/G14L
S.F Z,-,T ( avP Nrjt
Elevation of vertical reference point: STE-EL Slope at site:
/c 0, o~ ' -
SEPTIC TANK: Manufacturer: Liquid Capacity: p
Number of rings on cover : Tank manhole cover elevation: f.;'7.5'
Tank Inlet Elevation: 27,,g Tank Outlet Elevation: ` 7, 7S"
PUMP CHAMBER Npn.o .
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity o
distribution lines gallon: size of pump -head;
gallon per minute horsepower brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: Number o pits feet diameter-
feet liquid depth seepage pit in epipe-elevation _
bottom of seepage pit elevation feet. „
SEEPAGE BED SIZE: number of lines 2 width /z length/694~r the depth ,gyp
SEEPAGE TRENCH: width /Y'b''. length _
PERCOLATION RATE < « AREA REQUIRED 126,0 AREA AS BUILT lZloo -t
/ INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER $-S~}
DEPARTMEN 1 OF INDUSTRY, INSPECTION REPORT FOR O SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS v
PRIVATE SEWAGE SYSTEMS q' DIVISION
P.O. BOX 7369 O BUREAU OF PLUMBING
MADISON; WI 53707
CONVENTIONAL ❑ ALTERNATIVE Stale Plan D Number.
(I! assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
INSPECTION DATE.
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER:
t C
BENCH MARK (Permanent re erence point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST HET. PT ELEV.
fl r r c. I G~ ► r1 i i
Narr~oi PWmber: IMP/MPRSW No.. Coumy. Sanrtary Permn Number:
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
/ 7 ~J C PROVIDED: PROVIDED.
C l JS YES LINO DYES LINO
BEDDING VENT DIA.. VENT MATL. HNUMBER OF ROAD. 1PINE ROPERTY WELL. BUILDING. VENT TO FRESH
ALARM. + AIR INLET
FEET FROM
EYES LINO DYES LINO NEAREST _
DOSING CHAMBER:
MANUFACTURER [EDDING. JLIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTUHER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES NO DYES LINO. ❑.YES NO
4T To I LE FRESH
GALLONS PER CYCLE: PUMP AND coNraoLS OPERATIONAL NUMBER OF PEHTV IVVELL BulLOI ]v
(DIFFERENCE BETWEEN FEET FROM NE NT
PUMP ON AND OFF) DYES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I EH MAT w L AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: /
WIDTH LENGTH J I NO. OF DISTR. PIPE SPACING COVFH SIDE LDIA -PITS' LIQUID
f
BEG/TRENCH TRENCHES MATI.H1AL PIT DEPTH:
DIMENSIONS
I'51 F IL 1 DEPTH JDISTR. PI PF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL. JBUILDING. VENT TO FRESH
T771-111
.
BIL'A PIP, ABOVECOVER ELEV INLET ELEV END PIPES. FEET FROM LINE AIR INLET
NEAREST--►~
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the te.Xre of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound sys s to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the riteria for medium sand. TIONS MEASURED.
DYES LINO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
r~
DYES LINO DYES LINO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH/PED rl H OF TOPSOIL. SO jDED SEEDED MULCHED
cTNTFR EDGES DYES LINO
DYES LINO DYES LINO
PRESSURIZE_D_ DISTRIBUTION SYSTEM:
AIUTH LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BE OW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD ISTR PIPE MANIFOLDS MATERI' NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
Ei. EV.. ELEV. DIA. ELEV. PIPES. CIA
ELEVATION AND /
DISTRIBUTION
INFORMATION 'HOLE SIZE HOLE SPACING DRILLEDCOFy/EC1LY j' ICOVU'R MATERIAL PLAN$CALLIFT CORRESPONDS TO APPROVED
f/ f
EYES f` ENO DYES LINO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NBER OF PROPERTY WELL BUILDING
FROM uNE❑ YES ❑ NO YES NO REST-
4~ E
1 i
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATUR TITLE.
DILHR SBD 6710 (R. 01/82) - J
r
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'/s 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.
Property Owner: Mailing Address:
-'D. Rr4 F(v-E 14us
Property Location: City, Village or Township: County:
1I<)'/a NZ_'/aS jd /T21 NCR / E (or W % :St i
Lot Number: Blk No.: Subdivision Name: rNe~arest Road, Lake or Landmark: State Plan I.D. Number:
QT I IQ ""~~,ovt-: D (If assigned)
TYPE OF BUILDING 1 ~~aa
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
or 2 Family *State Approval Required. t,(
R111-
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY /;Z f A
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): l~I NeW ❑ Replacement 1:1 Experimental LJ 5eepage Bed E-1 Seepage Pit
< /0 ❑ Alternative (specify) ❑ Seepage Trench
/ 2, 4& ~r
/a 1.73
Wa~te_,r,S.u~ply: Owner's Name as Listed on Soil Test Report (If other than present owner):
L~J Private ❑ Joint ❑ Public 1C-
I, the undersigned, hereby assume responsibility for installation of the privat sewage system shown on the attached plans.
Name of Plumber: Signature: MP1MPR4W-N0.: Phone Number:
X56 ( ~Q6
Plumber's Address: Name of Designer:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent Fee: Date: Sanitary Permit Number:
'-A 1 APPROVED l ,
Lori • 00 f ❑ DISAPPROVED y
Reason for Disapproval:
Alternate course(s) of Action Available:
J
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. 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)
~ r
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION
P.O. BOX 796
LABOR•AND PERCOLATION TESTS (115) MADISO
N WI 3M7
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
' W i,,,/ /T2eN/R/?E(o Y -Z7' 12,4WEX ' fd
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
~
;'T'` G"-o, k to . e lzn-~ - loot S 2..
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: I T-R-OFFEE ` D R TONS: ER ION TESTS:
I!7Residence II!JJNew ❑Replace
7
RATING: S= Site suitable for system U= Site unsuitable for system V)rl / CONVENTIONAL: MOUND: JIN-GROUND-PRESSURE: SYSTE - -F'ILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
[XS ou KS au , ZS ❑u ❑ S au a S ou ~O&VZN o
f Percolation Tests are NOT required DEG%a TE: SY~T~M~ If any portion of the lot is in the
1Iunder s.H63.09(5)(b), indicate: -.01"94 1 Floodplain, 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. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- N' s r:1 ,
B- 2 for 16:1.5 c-/ /9 o Sid, 5' :1 e- ii 91
13- 5 lee, 3
13-
~f ,4 .'I J~ Jr Jf
B-
iol If
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P / Q
3 17 S
7AID 7-,6=i
P-
P- r` -
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. l d P_ J 71,-
S YSTEAII ELEVATION A/m 1C_ L
I,P,e&,p &-:i A ~tJe y
C]* 3
}
~r~ Axe ~ .._.,ar 3M 9►4r' ~x
' H
qoclpi,
j
.C v l
e e_
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 Wiscoonssiis5
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 W RE MPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
CST SIGNATURE
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 IN. 03/81)
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