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AS BUILT SANITARY SYSTEM REPORT
OWNER L TOWNSHIP SEC..j&TI-R/W
ADDRESS ~r ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
41_EVERYTHING WITHIN 100 FEET OF SYSTEM
- '
- ;.LA: - -
t7[a. f (
un
- - - - - - t- -
I di ate orth~A roW
SCALE :
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: /0Z) Slope at site:
SEPTIC TANK: Manufacturer: bi 1~s t~ Liquid Capacity: ,-,L~O
Number of rings on cover : Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
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 inlet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: `number of lines `-3 width lefigth-7~tile depth`'~_''
SEEPAGE TRENCH: width lengn-i
PERCOLATION RATE AREA REQUIRED 24D AREA AS BUILT e~_O zS
INSPECTOR
DATED PLUMBER ON JOBS,
LICENSE NUMBER Z~
r
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR O SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS C, 1 DIVISION
P.O. BOX 7969 ' PRIVATE SEWAGE SYSTEMS
BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL ❑ALTERNATIVE Stst
(I Plan l.D. Number:
I a :.Plan I1
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAPOF PER IT HOLDER: ADDRESS OF PERMIT OLDER: INSPECTION DATE
BENCHt MARK (Permanent reference point
) ESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF, PT. ELEV.
1, L ~1 u- C -j-
I 1(' l
Nance f Plumber: MP/MPRSW No. Count
y: r Sanitary Permit Number:
r
--i "A
SEPTIC r NK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCK( G COVER_
P V D: LI IPF30V OFD 1..._-_._
c~ -S 5 YES NO AS NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM:' _ LIN - AIR INLET: '1'
DYES LINO DYE'S LINO NEARESTM /11-1 ;
DOSING CHAMBER:
MANUFACTURER. BEDDING: CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES LINO LIQUID DYES LINO DYES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING JVINTTO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE- AIR INLET
PUMP ON AND OFF) DYES LINO NEAREST __j
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAME TEN MATERIAL AND MARKING
or excavation. Of soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTR. PIPE SPAC NG JINSIDE'~DIA P;d LIQUID
THE NCHES COVE L• PIT / DEPTH
DIMENSIONS I
GRAVEL DEPTH FILL DEPTH UISTR PIPE DISTR PIPE ISTR. PIP MA RIAL NO. DISTR. NUMBER OF R PE TY WELL BUILDING: V NT TO FRESH
9ELON/ PIPES, ABOVE COVER INLF I E V NU LE
AIR I
PIPES FEET FROM uT' ! '4Vw;~
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the textufq of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: e 1 mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the critero for medium sand. TIONS MEASURED.
DYES LINO
SOIL COVER TEXTURE PERMANENT
WELLS
YES MARKERS LI NO JOBSERVATION DYES NO
LI
DEPTH OVER TRENCH/ BEO DEPTH OVER TRENCH/ D DEPTH OFT P IL SODDED SEEDED MULCHED
CENTER. EDGES
DYES LINO DYES LINO DYES LINO
PRESSURIZED DISTRIBUTION SYSTEM: /
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GH L DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENC
DIMENSIONS r
MANIFOLD PUMP MANIF Lt STR. PIPE ANI OLD MATERIAL NO UISTR UISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAHKINO
ELEVATION AND ELEV. ELEV.. DIA LE V. PIPES DIA..
DISTRIBUTION
INFORMATION HOLE SIIF HOLE SPACING DHILLE CO HECTI.Y COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
YES O DYES NO
COMMENTS: PERMANEiNT ARKER OBSERVATION WELLS. NUMBER OF
I LRNE ERTY WELL. BUILDING
FEET FROM
6 DYES LINO OYES LJNO _ NEAREST
,r
1
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE ' TITLE
DILHR SBD 6710 (R. 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'h 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 Mast,
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must t;
included.
Propert _ Owner:
ry Mailing ,ddress:
1 t LAA1 2-
Property Location: _ C City, Village gLTownship: County:
(,V) '/a4fkJ ,S~ ~ ETC ; NC R i7 (or)
Lot tuber: Blk No:: Subd' Sion Darner
Neay2~t Road, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* ~ 111!~o~ `liz-131720(i Bedrooms:
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION ME NT (Specify)
SEPTIC TANK CAPACITY 444
7r"<- 114
HOLDING TANK CAPACITY 1-4169
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ED] Joint ❑Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Na i umber: % Signaiu MP/I /~$,5)(y p~Q ; hone Number:
Plumer's ddress f Name of Designer:
G:
COUNTY/DEPARTMENT USE ONLY
Si ture of Iss 'ng Agent: IFDate: Sa itary Permit Number:
1 ® APPROVED
.J ❑ DISAPPROVED
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-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
DEPAPT,`V1ENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION BOX HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
LOCATION: SECTT~ION:T~ TOWNSHIP/~: LOTNO.:BLK.NO.:SUB~DfIVISIONNAME:
Q
50 1AW1 JC7 / i ,QN/R/ 1 (or ,r 111.3 - Cf Ri Q eti
COUNTY: OA,44 R'S BUYER'S NAME: MAILING ADDRESS:
rd; . A ~ r 8~x lu 0 - 4 4 w~ S `L~o
USE DATES OBSERVATI NS MADE
NO. BEDRMS.: COMMER( ~?Al_ DESCRIPTION: W r" RUF ' DESCRIPTIONS: IPERCOLATIIN TESTS:
I N-idence I" ~e \ ~4 ~~A' I f 7W - / O
RATING: S= Site suitable for system U= Site unsuitable for system
rCWNV
NTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM- - IL DI R K: R~GbMMENDED SYSSTEM:(optional)
S ❑ x S ❑ U S ❑ U ❑ S U .i U r~ Oiu !/e u-'f 00114-0 I
If Percolation Tests are NOT required DESIGN ATE: SYSTEM El
If any portioViie lot is in the
under s.H63.09(5)(b), indicate: 4Floodpla' Floodplainelevation: IVA
PROFILE DES
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEEPPTTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)) n
B /(G / / , ~rr ~GC~ f t~ / ci~ ' r! S l (C02'r D s
B- 7 31 AASI
B c r ! f' ~~i /AK e- 7 rr At s
B- ( yff& AZe, ? /Ci r r ~.Z i /0 N 9^ lr3 f7h _r 0 OR,
.i
B ~(9r~ 1' ~~'SN '-~,cc Bl -141.2,- A0;, 9" B S~ act "
B-
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 PER INCH
P " ~i -3
P OL C' a2 6 3
P- 3 r, o
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 *II borings and the direction and percent
of land slop.
SYSTEM ELEVATION `T3 A,-X "
l~l ~-,Bvres B,/~,
P2 E1.2
r~..~ ~y a 3(01
P. 6. )qOe/zo Rd
R3 0
s e„s~ f~' ~o= ~ TN
/s 8 S
41
77777m Z
Pow Pnle o f
J 13.h. El. =/ate', Q O
1`~ Sy Sy(~s..'e.4s 7444
k• W, Carer
1,1o S7cfe_ F,fs l` des%leA• c.` 6,37 .
A-.~try .Sj#io Gv~o z ~ Ls f F~7-c , C ,3:3 ~(p kl~~(
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:
.061y e s t ~r 9y.3a--8';L_
ADDRESS: / CERTIFICATION NUMBER: PHONE~rNUMBER (optional):
(b cit s c wIG
CST A RE:
y
R
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
HR-SBD-6395 (Ni-
03!""`
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