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AS BUILT SANITARY SYSTEM REPORT
C Se's TOWNSHIP SEC 3 " TQN-l~ W
OWNER
t'? , Pr i tt c~ U
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ADDRESS 1r 5, ST. CROIX COUNTY, WISCONSIN.
2
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
OW--EVERYTHING WITHIN 100 FEET OF SYST i M-,--
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BENCHMARK: (Permanent reference Point) Describe:}]'
-TN .5/7
Elevation of vertical reference point:;, 1~} Slope at site:
SEPTIC TANK: Manufacturer: (~('jrtS~rs Liquid Capacity:
Number of rings on cover Tank manhole cover elevation: T
Tank Inlet Elevation: ;Z4~_& Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity oe
distribution lines gallon: sizeo 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 liquid dept seepage pit in epe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines, width length the depth
SEEPAGE TRENCH: width length "3 If n. ,
PERCOLATION RATE _AREA REQUIRED REA AS BUILT
INSPECTOR
DATED X 01 PLUMBER ON JOB r'
LICENSE NUMBER ~1r~-
w REPORT OF INSPF.CTI.ON - INDIV LDUAL SEWAGE SYSTEM
Sanitary Permit
State Septic
dAMI? /•~!!i_4!r 00 TOWNSHIP St. Croix County
oCAT10N Section..?f Lot # Subdivi_sion__-
.V11TIC TANK
Size - gallons Number of compartments
Distance from: Well Building 7/1 12% slope
H i g h w}a~t e r
PUMPING CHAMBER
Size gallons Puinp Man.uf -nc urer r Model Number
P) LD LNG 'T'ANK
t`
Size - g a 11 o n s Number o f C o m p a r t m e dt ti
I'urnper Aitarm System
i tanc•e from: Well ui]_ ing _ 12% slope
H i. g h w a t e r -
\KSORPT ION SITE,
litcl Trench
i ;i +ince from: Well B u i I d i n g 12% slope--_
ti ighwater
'vVi ORPTION (i1 IE DIMENSIONS CC
Width of trench tt Required area ft.
Length of each line ft Depth of rock below the 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
'T'otal absort ption area s ft T ype of Cover:
PIT DIMENSIONS
Number of Pits ~ GraveI around pits - yES no
Outside diameter ft epth below inlet ft
L=
Total absorption area` ft
Area required/'ft
I N S PI, T I TL F.
A 1111 R 0 V FD _ 1) A' I' I? 1.98 fff-__
R' E.IECTE 1) DATE 198
REASON FOR REJECTION
State and County State Permit #
PLB- 67 Permit Application County Per it #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER 0.F~ PROPERTYi Mailing Addrels :
oW'J 1~tRC.lr ~~c~ v'~ V!q-lam y76t~
B. LOCATION: '/4 V'14 , Section - N, RL_,A'(or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family / Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 4000 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete- r/ Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement I
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate -jy Total Absorb Area~Q sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: ✓ No. of Lineal Ft. _2CX) Width S Depth-LOL-Tile depth (top)e No. of Trenches _
Seepage Bed: Length Width Depth Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land A • Distance from critical slope
WATER SUPPLY: Private 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 Tgster,
NAME cI ,N Y%k4-1 CMG C.S.T. # and other information
obtained from (owner/guilder-). _
Plumber's Signature P/MPRSW# K' Phone # 224g-
Plumber's F.ddress
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 SE ONLY
Date of Application-,;?3 J1 Fees Paid: State C unty Da
Permit Issued/Rejt:Uted (date) - 02J Ifl Issuing Agent Name
Inspection Yes 4_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
:1.~PAR:MENTOF REPORT ON SOIL BORINGS AND s,af~Y UILDINGS
INDUSTF?Y- c IVISION
HUMAN REDLATIONS PERCOLATION TESTS (115) X 7969
k jAON~ 53707
LOCATION: SECTION: TLOT NO.:BLK. NO.: DlVfACM UA
i)-,"/4 44 Vic. /T z. N/R J; or) W Cea~
COUNTY: OWN R'S E: ) AILING ADDRESS: • ry,
r C), r- let r
USE DATESO ERVATIO p4 -_'S
1,-;4,/ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE ON L ON TESTS:
~L?Residence El New L?TReplace ~
S cn,Q,o lt-1p Gj~ n'l °"P k
RATING: S= Site suitable for system U= Site unsuitable for system 4 1
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FI L HOLDING TANK: RECOMMENDED SYSTEM: (optional)
Zs ❑u ❑s ❑u ❑s ❑u ❑s ❑u EIS ❑u
If Percolation Tests are NOT required DESIGN RATE:SM I 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 DE/PTH IN, ELEVATION OBSERVED EST.- H IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 C
I r etc c7 '4 rc~C Ce,, ' ✓c
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P_
P-
20
P-
P-
P-
PLAN VIEW: Show locations of percolation tests, soil bor' -Ad soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points s ow their location on the plot plan. Show rface elevation at all borings and the direction and percent
of land slop.
SYSTEM ELEVATION moo'' . d 'p G•-,,dc-
Pr 1 v -e_
~~Si 11CL t`~: f fL t)1 l L i
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1, the undersigned, hereby certify that the soil tests reported on this form were made by me in acc~r with the procedures Qt ods specified in th~ Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the b st of nowledge and belief.)
NAME (pr_ji~0: f TES S WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
j C+
CST SIG TUBE:
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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