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AS BUILT SANITARY SYSTEM REPORT
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OWNER TOWNSHIP SEC A T_N-R W
ADDRESS& d, 4,j ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
yERYTHING WITHIN 100 FEET OF SYSTEM
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I di a e oath Arrow
-FT III I I ISCAL~__: -I
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: We e--k ~ Liquid Capacity:
Number of rings on cover r Tank manhole cover elevat on:_,Kr,'
Tank Inlet Elevation: " Tank Outlet Elevation: rC>~t
PUMP CHAMBER
Manufacturer: Number of gallons
Jurnber of gal. pump set or a cycle gallons; totacapacity o
distribution lines gallon: size o pump head;
gallon per minute horsepower brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole ccver
Type of warning device
SEEPAGE PIT SIZE: Number o pits feet diameter
feet liquid dept seepage pit in epe-elevation
bottom of seepage pit E'.evation feet.
SEEPAGE BED SIZE: number c j' lines__,2_wi th I leTigth.2- tile depth--
SEEPAGE TRENCH: width length
PERCOLATION RATE- -AREA REQUIRED AREA AS BUILT
INSPECTOR
DATEDl JC _ PLUMBER ON JOB -
LICENSE NUMBER
L~'_~_ L -
I
W/ POKT Of INSI'LCTION - 1NUlVIVUAL SIWAGL SVMM
Savll tahr/ 1,ch 1114 1
St at. I . S e r r t 4 v
ZIM4 0ew4e-- 16- r, w~i0Y1.111 ~4-11-7 1.~1,o I x ~k oIIt/Y'111I .
Sec-Ci.or"Lot. p SabdiV.Cetion
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ko n4 NumbeA o6 compait.tmen.te
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Highwa ten -
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caUon4 Purnp Manu6ae-tu~Loc Model Nurnbeit
TANK
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Akatlrn Sijn tern
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('vrlyrh o6 Z1CY4e15 ht Vept.h o6 below
I,vfiwevo Yinve =..6t Storic o6 t&e.ncll crl. 111 It 100 (tit
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67 State and County State Permit #
PLB
Permit Application County Permi # '
for Private Domestic Sewage Systems County ~d.r~G
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
1
AL /C
B. LOCATION: tF '/4 Nit '/4, Section T,jr / N, R /7r(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 i~ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY A/ J 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
Lift Pump Tank or Siphon Chamber Total gallons Prefa concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: ~Aercolation Rate Total Absorb Area sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth 2" Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- 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 C S it T ter,
NAME j(: -7 ~Ai6/n.j C.S.T. # /r7//3 and other information
obtained from (owner/builder).
Plumber's Signature _ 2 MP/MPRSW# Phone
Plumber's Address L '
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 Be~ljow~ - FOR COUNTY AND STATE EPARTMENT SE ONLY
Date of Application Fees Paid: State C %unt C-~ Da
Permit Issued/Re}ee+ed (date) - Issuing Agent Na 7
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
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
EH 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
,w WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: '/4, '/4, Section ~,TI'L" N,R~Z~ (or) W, Township or Municipality
Lot No. , Block No. County
u division Name
Owner's/Buyers Name:t'" C~
'f
Mailing Address: O
TYPE OF OCCUPANCY: Residence No. of Bedrooms- MMERCIAL
~rF f
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTE OTHE
f,
DATES OBSERVATIONS MADE: SOIL BORINGS
5;2 PERCOLATION TESTS /
SOIL MAP SHEET NAME OF SOIL MAP UNIT
PERCOLATION TESTS d
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN NEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/ IN
BER 'j 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
l / 3
P- h •e. Ci re- 're y 73 4r- 3-
P_ 2, q~z e- _5
P-~
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 2. -7zo 7 D r
B- r✓ J
B-
B-
B-
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan he location a are feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 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. ,r
Name (print) A Certification No. j f
Address y u/ F
.Name of installer if known
Copy A -Local Authority CST Signatur
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