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AS BUILT SANITARY SYSTEM REPORT
OWNER /I+IY' y ~ :H ~~'L=/i3r/~ TOWNSHIP SEC._ T N-R
ADDRESS l~ c l T s t C ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
InL EVERYTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe: 3 .60R, L0% 5A4I~A
Elevation of vertical reference point: /4p Slope at site:
SEPTIC TANK: Manufacturer: ~g 's Liquid Capacity: 106,0 LIJ Number of rings on cover : Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: /
PUMP CHAMBER
Manufacturer: Number of gallons
Dumber of gal. pump set or a cycle gallons; total capacity of
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 dept seepage pit in eet pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines_y_~wi thleiigthj6_tile depth ly''
SEEPAGE TRENCH: width length
PERCOLATION RATE y-3 -,Z REA REQUIRED 616- AREA AS--RU-ILT
INSPE 0
DATED y PLUMBER ON JOB G
LICENSE NUMBER- 2XQ_5__
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit
State Septic
NAME OWNSHIP St. Croix County
1,0CATI ~ Section32-Lot # Subdivision
SEPTIC TANK
Size gallons Number of compartments
Distance from: Well Building -:y! 12% slope
Highwater
PUMPING CHAMBER
Size gallons Pump M of t rer Model Number
HOLDING TANK
y
Size gallons Nuuob r of C,o par ents
Pumper ( Al,i System
Distance from: Well •'Aui ding 12% slope
Highwater ;
ABSORPTION SITE
Bed Trench
Distance from: Well Building 12% slope
Highwater
Y
ABSORPTION SITE DIMENSIONS
Width of trench ft Required area ft.
Length of each'line ?4 ft Depth of rock below tile in.
Number of lines Depth of rock over the in.
Total length of lines- ft Depth of tile below grade in.
Distance between lines ft Slope of trench in. per 100 ft.
Total absortptton area ft Type of Cover:
PIT DIMENSIONS
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Number of pits avel around pits yes no
Outside diameter ~t epth below inlet ft
Total absorption area j' ft t--
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Area required ft. _-T-
INSPECTED BY T, -1 _
APPROVED DATE 198
REJECTED DATE 198
REASON FOR REJECTION
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LB State and County State Permit #
P 67 Permit Application County Permit
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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:
B. LOCATION: % Section , T N, R 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 X, Duplex No. of Bedrooms ; 3 No. of Persons
D. SEPTIC TANK CAPACITY ~L~tx Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify)
New Installation X Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E_ EFFLUENT DISPOSAL SYSTEM: Percolation Rat" Total Absorb Area sq. ft.
New X. Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length -7 Width Depth tc Tile depth (top)_.~ No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- k Distance from critical slope
WATER SUPPLY: Private DC 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 Certified Soil Tester,
NAME ~~%✓/~S AC.S.T. # and other information
obtained from e 4v-- (owne b4bou-i .
Phone Signature>
M PRS # :7 `1%
Plumber's Address ~`>i;_r~~Y•= [.G/.`
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.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State County Dat
Permit Issued/Relented (date) Issuing Agent Name
Inspection Yes -It- 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
EH 115 7-
Rev. 9/78 toe,- Yn./
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
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WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES s` =
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION .y'/4 /4,Section j%G- TN,RI vr?+~
W, Tow, shi p
Lot No. i , Block No. ' s i ' ~_\Lf:t IC L , ounty Q( Ak
Subdivision ame
Own is/Buyers Dame:' - ` = -
Mailiri `Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT -ALTERNATE SYSTEM OTHER
DATES OBSERVATIO DE: SOILBORINGS PERCOLATION TESTS
SOIL MAP SHEET ( NAME OF SOIL MAP UNITS:
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
DEPTH CHARACTER OF SOIL RATE
NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
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SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
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PLAN 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 area needed for building type and occupancy SEE:- 1=L 5' il-±O d cate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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r, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the proce uses 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? ME!, Certification No.
Address 2 J f J~-(I e1 - } L
Name of installer if known
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Copy A -Local Authority CST Signature
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