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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. Tj?P-RebW,
ADDRESS~- r , ST. CROIX C~bUNTY, WISCONSIN.
;SUBDIVISION LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
7
III, QW EVTHING WITHIN 100 FEET OF SYSTEM
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I di a e No th Arrow
SCLL ~p i
1?I. ACHMARK: (Permanent reference Point) Describe: Cx" i pi i
h:l,,vat ion of vertical reference point:, `4 Slope at site:~Q! _
SLPTIC TANK: Manufacturer:",
Liquid Capacity:
Number of rings on cover manhole cover elevat.d
Tank Inlet'Elevation: Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer .j Number of gallons
Nutaber of gal pump" set or a cycle gallons; tota cacity-0-
distribution lines gallon: size o p/U head;
gallon per minute horsepower- 474 /1 ran name of pump
and model number` i -
Type of warning del' ce
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: Number o pits eet diameter
feet liquid dept seepage pit in e-t pipe-elevation `
.79
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines_ wi th_ _leagth 4/0 tile dept
SEEPAGE TRENCH: width len
PERCOLATION RATE_ AREA REQUIRED t REA AS BUILT_
INSP CTOR GC-
DATED / PLUMBER ON-JOB
LICENSE NUMBER
REPORT 01: INSPECTION - INO IVIDUAL SI. WAGL SySI1M
ti «vl i t-tz It t{ I' ~h rrt t f 9 r
S to t~Septa t'lGxo~ e
NA;ut lownah ip__ts-/_~___Q~i Crtu4x Cuuvltt{
I ,r t t,,I ~ ~_S.e.cttian Lo -t ti it bd4VA,5Ion
ITI IC TAN K
S ( : •
ga('kUn~S Number 06 eUmpan:tmen:t6
0(_5 tovice (tom: Weet~ Butikdting 12 o a eopv-
HighwateA_
PUMPING CHAMBER
Size 9aeton.e Pump Manu ac.ttune~t ! MUdef-Numb e-tI ;
~tt;f
HOLDING TANK
St ze _ akPonS Numbett. o6 Compan.trnent5
P(trnpe n Atanrn. St/g te.m
Ut1~tavlce 6utiZd4'n9- 12'0~ hYope----
H ighwaten
ABSORPTION SITE
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1! ( a u m : too f f B icy. di n g C---1 2 L M o p e---
If.< c{hwate ~i
A1;1,01.PI ION SITE DIMENSIONS
w.<dth o6 tAeneh 6t Requ,cn.e-d area -C - (t
Len{{th i,6 each fine ---~t Dept!t 06 ~(Ocfz beYaw t.i.Pe
Numbcit o6, I'.<vte, Depth o A Aoch oVe~l tife <n
L Ti,ta4 Y.ertgth a6 Xi.nee 6t "Depth i,( t`i, e bet!ow gnade ~s ivt
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{NSI'1 OTLU 8V C~2 TITLE
11,11 -it (111-0 DATE 191
1,1 ASvN LOR REJE-Cf-10-
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PLB 6 7 State and County State Permit # 1& 11C2.e_
Permit Application County Perm t #
for Private Domestic Sewage Systems County ,
"DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWN FR OF PROPERTY Mailing Ad ess:
~
71 a3"~FnJ
13. L '/4 '/d, Section T N, R E (or) ~W„ L o t # City
,vision*ame, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPAN *Commercial `Industrial_ "Other (specify) -Var ance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPAC Y Total gallons No. of tanks
Prefab concrete _Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement A-'
Lift Pump Tank or Siphon Chamber_4zTotal gallons Prefab concrete-7,SPoured-in-Place -Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement Alternate (Specify) `z
Seepage Trench: No. of Lineal Ft. Width th Tile depth (topes) No. of Trenches
Seepage Bed: Length'Jf Width Depth Tile depth (top) No. of Lines- .-'-y .914 Seepage Pit: Inside r=e r, 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 Cer fled Soil Tester,
NAME rh1 C.S.T. # and other information
obtained from , (owner/builder).
Plumber's Signature W/MPRSW# 7~3 Phone
Plumber's Address
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 Cr
Date of Application C:% V fl ~ Fees Paid: State/. County Date (.1
Permit Issued/Re7eeted (date) tl_Issuing Agent Name, e'2
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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO-.:BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
rr-~ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI R TONS: ER LA ION TESTS:
L~1Residence ❑ ew flRe ace I.' ~ '
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: JIL HOLDING TANK: RECOMMENDED SYSTE :Ioptiona
as [:]U as ❑u [IS E1u EIS au as ❑u - -
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. 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-
13-
13-
13-
6-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- ,
P- _
P-
P_
P-
P
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
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I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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 NUMBER: PHONE NUMBER optional):
CST SIGNATURE:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DI LHR-SB D-6395 (N. 03/81)
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