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OWNER _DalrMe TOWNSHIP, ~~v;~ SE N-R~fW
r!DDRESS_f~,•~,,'~ ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
S OW -EVERYTHING WITHIN 100 FEET OF SYSTEM
Off
r
~ x rr
r cry"
dirate No th Arrow
S C L
11E1
BENCHMARK: (Permanent reference Point) Describe: A(t) Cert,"C7-. C1C ll°4'Se' e71- -e?e ~
Elevation of vertical reference point: 1,0ol Slope at site: / el'o
SEPTIC TANK: Manufacturer: 41ZAe- e-XS Liquid Capacity: /000
Number of rings on cover : z9WIt' Tank manhole cover elevation: 4- -
Tank Inlet Elevation: ~I7" 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 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 feet diameter
Feet ? iquJi deep seepage tai 4n_-et on
Hfi4 f-rl of w± 1t e. e tion feet .
SEEPAGE VED SlI : num er o Y nam 7) ytta J +~wgt if5~ t 4 r i 1 _
SEEPAGE TRENCH: width length
PERCOLATION RATE REA REQUIRED K/,S'0 ARE AS BUILT b
INSPECTOR
DATED C PLUMBER ON JOB
LICENSE NUMBER ,yam p~
REPORT 01 INSI'ECTION - INDIVIDUAL SLGIAGL SYSTLM_---
Sand ta?rtf I'elttn<
S.tat(, Septic
ownAltipOW1 Sfi. l'~tu<x ('uunfit/
111C(l l ((1H Se.c tion_1_7 Lot N Subdl(vA"6 i on
I I'7 I C TANK I
0 gae -Y_oms Numbers o6 eornpantmevetA
0('ti tancc {,nom: Glee(- ButiYd~ny---0 12`AYopE!
Highwa te.n
I'fIMVING CHAMhER
_gat(on's Pump ManuAac.tunen Modck Number
IIi)IUIN(, -1 ANK
tit:'t' claef'ovtA Number( o~ Cnmpantment15
I'~uil'r''t A('a~trn St/n-tern
I)t ttrt,. Onont: Wvee 6u4'i,d4vty 12`a AXope
H<.ghwa.te4
A6.ti01:1'f ION SITE
8etl T_ Tti encIt
Ur , tttvtre (,norm: We Pk Qu.iPd•tn9 72 Aeope-- ~ -
Ili u6twate"t
AI,I'I 1ON tiI It DIMENSIONS
(0((1(11 (1() tn.ench h.t Req t.t,<it ed area t
Ictt,tth o6 each ('.ine fi=t Deptlt oA rock beeow t,i.Ye ~i <n
/Nunibr of e,(vte5 Depth oA noeh overt t4fv
l~ 7r(rtY Ye.n.g.th 06 f4"nv6 ~LlQ A .t Dept Gt oh t%Ye be Yaw ta~tude <rt
y -
1)r tavtr'e be two epi e,( nee C~ ( t Z.-
JYupe of t~tencGt in. ~.~c~ir 100 At
Iota l' abAonpt -i-on a neu (t lype cq Coven. I'apcrt oft A thaw
1'11 'DIMENSIONS
Number ()A p, to GftaveN ano7(~f i.t6 y C A nU ~
oil tA;de diameters At Deptlt bveow meet (t
. iy7
Ioi`aC ab6onpt-uo area (t.
i
i
Air e a It e qu.Lne d (-t
INS P[ [TED BV T I T L I
nrI'KOvI D DATE 19 K
I
RIItCHV DAII !tx
RI A. 0 N I OR RI JCC-1 10,
r
PLB 67 State and County State Permit #
M-k Permit Application County Permit # 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:
~c; ✓ S V l~ M Q~~
C/ L'u
B. LOCATION: '/a, ection L2, T~ N, R~ P (or) W Lot# City
Subdivision ame, nearest road, lake or landmark Blk# Village
Township ,4,4,cf c. ,
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family ) Duplex No. of Bedrooms No. of Persons_
D. SEPTIC TANK CAPACITY 1000 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 Replacement X
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area ~r~-l-sq. ft.
New Replacement X-Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: _)<_Length OW ~~R Width Z 2 '_Depth 346 ' Tile depth (top)-No. of Lines 7*r- y
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land "I 2d Distance from critical slope
WATER SUPPLY: Private X 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 =✓e°/2&- -f- C.S.T. # and other information
obtained from cvn~c (owner/builder).
Plumber's Signature MP/MPRSW# MP 4+x'1 Phone # 7J5-6,?y- 3- 7:x'
Plumber's Address t;5 09 Z w .N L-J"
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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_«._..,,n3 gym...... s ._e... a Y ...F . , m n.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State County - Cy Date
Permit Issued/RrtecrM (date) (o Issuing Agent Name
Inspection YesNo State Valid# Date Rec'd
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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IN7t.FSTRY, DIVISION
LABOR ANA PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS ~'1 I N,WI 53707
3707 ION- LOCAT
A,[ f LOT NO.:BLK. NO.: 7 IVI AIN:
r- 50N/RAO J (or) WITOWNSHIP/M
IA; r
COUNTY: OWNER'S BUYER'S NAM MAILING ADDRESS: l~ j-
USE DATES OBSER ONS
NO. BEDRMS.: COMMERIIAL DESCRIPTION: PROFILE ONS: ER A ESTS:
,Residence ❑New Replace .6-
RATING: S= Site suitable for system U= Site unsuitable for system L
CONVENTIONAL: JMIIV-GROUNNcD-PRESttS11URE: SYSTEccM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®J ❑U ❑S ❑J ❑U ❑J ❑U ❑S ❑U
SYSTEM EL V.
If Percolation Tests are NOT required DESIGN RATE: 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. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
13- :5 1 '72 I 77 k ~r~ oI
13-
B-
13-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIO 1 PERIOD2 PERIOD PER INCH
P- _-76 C i
r
P- 3 G" i h~
P- ' ltl
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 /Y- On 119C PCs,
~~sn f Road
&POAP-1 oft C'st 51"
I
100,0
155
13 60re KQ e' S
0- _cp
Perk xl . , Fls, xrstin_
Krouse t N
Scale
1 ; O' a
10-0
la
q
Well
R '4
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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
C/ L71 S- y-,Y,-3 7Y
CS IG /aTURE:
(C 41 2 %i.J+
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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