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AS BUILT SANITARY SYSTEM REPORT
OWNER < ka 14s me, e+t rk, TOWNSHIP 4 ! ~~f SEC . ~T j` N-0 6W
ADDRESS ?G S- Fj e)o d eq e ti_ d Wo&j ST . CROIX COUNTY, WISCONSIN.
~f ~ s rp cat '41~~ r✓~ '
SUBDIVISION LOT LOT SIZE'
PLAN VIEW r, ~i~~FU
Wit' 1$tg
I0111.r'r
Distances and dimensions to meet requirements of H63 ~
SHOW- EVERYTHING WITHIN 100 FEET OF SYSTEM
w~
41
- - 4 - --11
I di a e othTArrow j
J SC LI: ^1 i I T- I
IflENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK:' Manufacturer: I.J.'e.s e~ Liquid Capacity: /0 u y
Number of rings on cover : 2 Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump-set-Tor a cycle_ gallons; total capacity o
distribution lines gallon: size o pump head;
gallon per minute horsepower ran 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 eet diameter
feet liquid depth seepage pit in et pipe-elevation
bottom of seepage pit Elevation feet.
SEEPAGE BED SIZE: number c f lines 3 width IQ' le igth3 6,the depth
SEEPAGE TRENCH: width len th.
PERCOLATION RATE_ REQUIRED c AREA AS BUILT elf-
INSPECTOR
PLUMBER ON JOB~j
DATED
LICENSE NUMBER =9.
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit
State Septic
A M E j/ TOWNSHIP St. Croix County
OCA7TIION Section oLot # _ Subdivision---
I?PTIC TANK
Size gallons Number of compartments----
I -
istance from: Well RuiI- di.ng _ I2% slope
Highwater
'LIMPING CHAMBER
Size gallons Pump Manufacturer _i ___--Model Number - _
IOLDING TANK
Size gallons Number of Compartments
Pumper Alarm System_____
)i.etance from: Well Building 12% slope
Highwater
d3SORPTION SITE
Bed Trench
istance from: Well r!\ I Building 12% slope
Highwater
,IiSORPTION SITE DIMENSIONS
Width of trench ft Required area ft.
Length of each line ft Depth of rock below tile in.
Number of lines Depth of rock over tile in.
Total length of lines ft Depth of tile below grade-- in.
Distance between lines ft Slope of trench------in. per 100 ft.
Total absortption area ft Type of Cover:_.__ 11IT DIMENSIONS
Number of pits J. Gravel. around pits __yes _______no
Outside diameter f t Depth below
Total absorption area ft i
Area required _ ft
INSPECTED BY TITI,"
APPROVED DATE l98
t FJECTE1) Ut1'l P: 1 9) i
:F,ASON I,OR REJECTION
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% 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: t~
Property Location: City, Village or Township: County:
4V1.S iT ' N/R /6 ! (or) W 4f qZ LTG/Zvi ~e
lot
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYPE OF BUILDING
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 QOQ X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA ~r
(Minutes per inch): PROPOSED (Square feet): tai 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):
X Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: MP/#ARQA .IPNo.: Phone Number:
Plumber's Address: Name of Designer: g)l ?r 91,rlo:~z
COUNTY/DEPARTMENT USE ONLY
Signa re of Issuing gent: Fee: Date: Sanitary Permit N tuber:
XAPPROVED
❑ DISAPPROVED `
eason 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 (N.03/81)
DEPARTMENT OF. REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDOSTRY, CC DIVISION P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
LOCATION: SECTION:
TOWNSHIP/MUNICIPALITY: LOTNO.:BLK.NO.:SUBDIVISION NAME:
I r, A 2,
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
r
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: R TONS: PERCOLATION TESTS:
Residence :3~ P.New
❑ Replace 1.4
RATING: S= Site suitable for system U= Site unsuitable for system 1G d
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
%S ❑U oS au is ❑U ❑S ❑U os ❑U L.~
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:
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.)
r
B-
B-
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- 6" 3 3 3
P ,v
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
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Ne, XT
44 0. K A *1
IS
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'Pox Tw!;
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l~~ tT
Cv0n.,077'
,
SEC-
r / • ~Zfit.G Z
A ~..j XMIC h; 711 ft ~ `T Y /Z. k
P~ 17
1 -7 5Yn,4 1' c,?_--~ - j. sT s; G ~ T ,
1, 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:
Z_ 237-9/
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.
DI LHR-SB D-6395 (N. 03/81)
1
EH 115
' WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TES
LOCATION: k4, 4, Section , TR &f (or) W,Township or Miuzisi~
Lot No. , Block No. County ' Ra I
Sub ivision N We Owner's Name: R d P R _
Mailing Address:
TYPE OF OCCUPANCY: Residence X No. of Bedrooms Wd Other
EFFLUENT DISPOSAL SYSTEM: NEW x ADDITION REPLACEMENT ~y
DATES OBSERVATIONS MADE: SOIL BORINGS PE~R'C''OLATION TESTS 9 j- g 70
SOIL MAP SHEET ^ A6, SOIL TYPE i11 ~Z`I S'6i~1 cry ,LOA r►~-
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
i
Coe v)? AL ~Vo
N
if V I! if
SOIL BORING TESTS al<
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES I/ OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)l~
It, f
_ c cr
7a 5r3.h
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>1 194 LA
t~ s3
> 1,5
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas In icate number of square feet of absorption area
needed for building type and occupancy. _R/'I 'CJ~4 - t ~ Indicate scale
or distances. Give horizontal and vertical re erence po ts. Indicate slope.
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94
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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
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. t~
Name (print) E v E 9 et Certification No.
Address 7;6A-1 W t ~7l
Name of installer if known V A-7 /V A/ `
CST Signature '-w'
j COPY A - LOCAL AUTHORITY
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