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AS BUILT SANITARY SYSTEM REPORT
zzl- 11: t TOWNSHIPZSEC.-/ T N-R/-, W
OWNER
/ ST. CROIX COU TY, WISCONSIN.
ADDRESS y- Atlv-
LOT LOT SIZE
SUBDIVISION
PLAN VIEW
Distances and dimensions to meet requirements of H63
Qy yERYTHING WITHIN 100 FEET OF SYSTEM
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At
BENCHMARK: (Permanent reference Point) Describe:-/',,,,..,, to(~ `
Slope at site: / '7v
Elevation of vertical reference point:
°
SEPTIC TANK: Manufacturer: 1, i n tii d Ca Tm c` i t- y
~e.?
Number of rings on cover )ne Tank manhole cover elevation: g ,
Tank Inlet Elevation: 9i'S` Tank Outlet Elevation:,-"-'
PUMP CHAMBER
Manufacturer: of gallons_
Number of [ oE.a ~capacity o
Number of gal. pump set or a cyc e g ; t head;
distribution lines gallon: size OT pump ran name ea pump
gallon per minute horsepower _
and model number '
Type of warning device
Number of gallons-,
HOLDING TANK: Manufacturer
Elevation of manhole cover
Type of warning device um er o pits eet iameter _
I N~ SEEPAGE PIT SIZE: seepage pit in et pipe-elevation _
feet liquid dept feet.
AP[" bottom of seepage pit e evation
th leiigthytile depth'
SEEPAGE BED SIZE: number of lines- wi r> ~ length
---T -
[ f SEEPAGE TRENCH: width length REQUIRED REA AS BUILT GO - -
PERCOLATION RATE
W1 A INSPECTOR-
PLUMBER ON JOB
_ 4 - -
DATED LICENSE NUMBER /11
Rt PORT Of TNSPt CT ON - INDIVTDUAI- SIWAGE, SVS RM
4s Sang taIt If I'cRrnt
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tit PfiC TANK
SI-ze gakTanS Numbers o6 eampan.tmen.-t'5
Dchto nce (Itam: WcP.4' Bu_li,e&i-nq ✓ 120 5X-a•e
to a tc ri
PUMPING CI(AM6ER
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LIOLDING TANK
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A6SORPTION SIT(
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AliSORPTION SITE DIMENSIONS
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PIT DIMENSIONS
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INSPECT' V- TITLE
nRrvtD DAT( _
/
t?f JECTE D DATr I v
Rt ASON 1 0 R Rf JI CT 10 N
I
State and County State Permit # /
VLB 67 il County Permit #
Permit Application y
for Private Domestic Sewage Systems County 5 O
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
C, i4e, e- Aj
AA-
B. LOCATION: % Section T
.U 4t
N, R (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 t Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 100 4 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete 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 J Total Absorb Area sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length F Width--Depth Jy~ If
Tile depth (top) No. of Lines 72A~Q
Seepage Pit: Inside diam"%, eter Liquid Depth No. of Seepage Pits
Percent slope of land. SIB 0 f' e 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 Soi Tester, LL
NAME ~IQ~ f"f O.L. T C.S.T. # and other information
obtained from G~1N (owner/builder).
Plumber's Signat re MP/Mfogh!k# 1,4 F Phone #7/S-6ff 4- 6ff 79
Plumber's Address rJ I'S
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 d Fees Paid: State , o-v Co nt 0~tj Date G►
Permit Issued/Rsjeeted (date) Issuing Agent Name
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
state (pink copy) 4. Plumber (canary copy)
Revised Date 7/1/78
E~U` j15 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATI '/a, Ya, ction ,TN,R jlp (or) W~ Township or MtreiplPty
Lot No. o. County
f) Sp4division amen jC g
Owner's/Buyers Name: ~I ~
Mailing Address: 'J W +J LJ ~ S
TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW -REPLACEMENT- SYSTEM
DATES OBSERVATIONS MADE: SOIL BORINGS -5'- 49 PERCOLATION TESTS --6^ A - O~
SOIL MAP SHEET Z? NAME OF SOIL MAP UNIT A10C s- 2- V-4 Ae4,t-"-4
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 MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- -3 If
i ( if go
P- CA A " 5,
11
P-3 3IC, Ao" 7/t o o z 6-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES OBSERVED ESTIMATED HIGHEST TEXTURE, MOTTLING AND DEPTH TO BEDROCK
IF OBSERVED IN INCHES
B- °2" If > S-4M - Z) rr :3 rr
B- `t er if _ :7 rt it y !r
B- ~ F !f fi 11
B-
B-
B_
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 9 Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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I, the undersigend, 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.
Name (print) Certification No. 6ir_ 5, °j(`/
Address A c~ y t ►J L~J I S
Name of installer if known a
Copy A - Locoll Authority CST Signatur
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