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1.2 -
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM Sanitary Permit ,z19
State Septic 7_
:1AME_ ~T hnedep TOWNSHIP Etfj~e St. Croix County -So LOCATION S Section/elLot # Subdivision ~;4~
''EPTIC TANK O~~J ~CK)3 -
Size, is gallons Number of compartments
ii.stance from: Well Building _ 12% slope
Highwater _
PUMPING CHAMBER
Size gallons Pump Manufacturer -`--Model Number
IIOLD ING TANK
Size gallons Number of Compartments__ _
Pumper Alarm System-
uistance from: Well Building 12% slope _
Highwater
ABSORPTION SITE
Bed Trench
Distance from: Well Building 12% slope_ _
Highwater.
ABSORPTION 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 the below grade in.
Distance between lines ft Slope of trench- __in. per 100 ft.
Total absortption area ft Type of Cover:
PI-T DIMENSIONS
Number of pits Gra'Ve.l around pits yes _ no
Outside diameter ft Depth below inlet- __ft
Total absorption area ft
Area required ft
INSPECTED- BYTITLE f
APPROVED a DATE t 198 r
REJECTED DATE _ 198_
REASON FOR 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'/Y 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:
Jeffery Schneider Baldwin
Property Location: City, Village o Townshi County:
SW t/4 NW '/4S 12 /T 26 N/R16 E (or)41V) Eau Ga a St. Croix
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
j Country Estates County Trk "B" (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
❑N 1 or 2 Family *State Approval Required. j
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY 10ou x X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: Weiser Concrete Products Inc
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): ® New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit
j0 900 sq ft. ❑ Alternative (specify) ® Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
® Private ❑ Joint ❑ Public Jeffery Seheider
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature- MP/MPRSW No.: Phone Number:
Stephen L. Aeby ~ ld ( 696) 2407
Plumber's Address: Name of Designer:
Woodville, Hi Stephen L. Aaby
COUNTY/ DEPARTMENT USE ONLY
Sanitar~ly'Permit Number:
ISig to of IssuiFn A nt: Fe/e_: Date: _ C
IT 13d APPROVED Y
LL2~C tPl / fJ DISA PROVED /O 1?1:
~ReAon 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-
stailatiOn. 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)
OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AN P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
LOCATION: SECTION: N Rff I TOWNSHIP/MUNICIPALITY: LOT NO.: BILK. NO.: SUBDIVISION NAME:
(or) 3
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DES RIPTION: 1PROFIL DESCRIPTIONS: PERCOLATION TESTS:
Residence XNew ❑Replace
r- - ~f
RATING: S= Site suitable for system U= Site unsuitable for system 7
CONVENTIONAL: MOUND: JITANK: RECOM ENDED SYSTEM: (optional)
S []U OS ❑U ❑S U
, o as❑u osau
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V I If any portion of the lot is in the
under s.H63.09(5)(b), indicate: '1141611 I` 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.)
B- ! r OCR
B- G I s2 L' Q". S/L. YJ n. SZ
B- C; 41
B-
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_ 30
P- `7`0l a 3 a , Zit 34
p- lei
P-
P-
P-
PLAN VIEW: Show locations of percolation tests, soil borings dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their ocation on a plot plan. Show the surface elevation at all borings and the direction and percent
of land slop. 4*
SYSTEM ELEVATION
T
pc7- ; x
O ;Tc,
IO3
x 05
,
E
55
X 3 x _x x x X x x_ x , x,. x_.....x x..__x yt x x x x x x x x
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:
7 tv N e~ -
-I Ar 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.
DILHR-SBD-6395 (N. 03/81)
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