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AS BUILT SANITARY S'-,'%:' .LEM REPORT-
OWNER TOWNSH P z , . SEC .~~T : N-l/jW
ADDRESS ST. CROIX COUNTY, WISCONSIN.
Ayk.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
_ YTHING WITHIN 100 FEET OF SYSTEM
10
_ i
I di a e NO th Arrow
S C L - 't
T /
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer:
AA L~>,,,~ Liquid Capacity: Number of rings on cover Tank manhole cover elevati
f Tank Inlet Elevation: Tank Outlet Elevation:
I
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cyc e gallons; tote capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower bran 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 et pipe-elevation
bottom of seepage pit elevation _ feet.
SEEPAGE BED SIZE: number of lines width leiigtl the depth-2
SEEPAGE TRENCH: width length
PERCOLATION RATE . "t AREA REQUIRED - AREA AS BUILT -t"
INSPECTOR 1~~^
DATED > PLUMBER ON JOB
LICENSE NUMBER______ /.4Z
" REPORT OF INSPECTION - INDIVLDUAL SEWAGE SYSTEM f.
Sanitary Permit
State Septi
NAME~~G~ S TOWNSHIP ~~D St. Croix County
- Y
LOCATION SC Section) Lot # Subdivision
SEPTIC TANK
Size' gallons Number of compartments
Distance from: Well Bu i IdIn ti 12%
g = slope
Highwater
PUMPTNG CHAMBER
Size gallons Pum Man,; facturer Model Number-----------
I I O-L D-1-N-CTANK
Size - - gallons Number of Compartments _ -
i
Pumper larm System
f'
Distance from: Well Building - - 12% slope
HLghwater
ABSORPTION SITE
Bed Trench
Distance from: Well Building ✓ 12% slope
Hi.ghwater
ABSORP'T'ION SITE DIMENSIONS
Width of trench-_- f t Requi red area_____Z f t .
e
Length of each line ft Depth of rock below the in.
Number of lines Depth of rock over tile in
Total length of lines l ft Depth of tile be Low grade in
Distance between lines ft Slope of trench in. per 100 ft.
Total absortption area ft Type of Cover:
P1T DIMENSIONS
Number of pits----_- Gra el around pits----yes no
Outside diameter f De th below inlet ft
Total_ absorption area ft
Area required _ t -
INSPE ` j TITLE
APPROVED DATE Q--/ - L y8
REJECTED DATE c` 198
REASON FOR REJECTION (n
l`w1
V`~
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PL13 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 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:
Property Location: City, Village or Township: County:
<k-'/456,'/4S /I ✓T 3V N✓R j-k or) W ~Ic_',,.,.~-~o cu S ~ra ~,x
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
r (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedroomsi-.
1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY / ✓
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): )4 New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
7 (C7d4+ ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation oft private sewage system shown on the attached plans.
Na a of Plumber Signatys~: MP/MPRSW No.: Phone Number:
i
j,O
•1..._.' / 5763 (7th )~zs+!~
Plumbers Address: LL ` Name of Designer:
~F t ~l G ✓
COUNTY/DEPARTMENT USE ONLY
ure of Issuin Agent: Fee: Date: Sanitary Permit Number:
APPROVED ~J
L/f Q c~ 9"dC f~ / ❑ DISAPPROVED /
Xliqeason for Disapprova :
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-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DII-HR-SBD-6398 (N.03/81)
NoUIR EN: OF REPORT ON SOIL BORINGS AN & ~'~VIIS~ON
LABOR AND PERCOLATION TESTS (115) "a z0* ` P.a: 796
~G MADISON WI 53707
HUMAN RELATIONS 7
4CIr
LOCATION: SECTION: T0WNSHIP/MHN+e+P7tt7TY: LOT NO.:BLK. NW DIVISION NAK
/5~4
i8 /TN/Rlg(or, ~«i~,r,,.~ T.
J
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
rl ti 1 t .1 /7~/~+'L i j;..✓ A.i Y rr_r
-ST C Z _0 USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence XNew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system r..ry r j s 1
CONVENTIONMOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM' (optional)
1ESOCESOU1 ®S ❑u oS ®u aS PA
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL
I If any portion of the lot is in the
under s.H63.09(5)(b), indicate: 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.)
13- Sq n G
we's I?
N '
B Sg
o-4 Is
B- S^ gy ~S,-g~, ~y
C> r? I is IS_k - I`I y
B- (v ~7 9W
~ I IS a( ) .r t b.7 S,r
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD PERINCH
P_ ~C rV.,GC'
P_
P- I/ O ►V , .-j
P- '
P- S'
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
F
y [
~~p
84
911
.
R f1s ' -r~.
443rd ~t NG A, i`r e-
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 NUM ER: PHONE NUMBER optional):
!L'Ew •c,. mr Ld-Zs. 5-,S- 3 / -9&, - `i3s
CST SIG URE.,
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
i DILHR-SBD-6395 IN. 03/81) -
57
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