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AS BUILT SANITARY SYSTEM REPO4R~'
C OWNER TOWNSHIP SEC -~4 TqN-R4~W
ADDRESS I ZbL4 F70x CROIX COUNTY, WISCONSIN.
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SUBDIVISION LOT LOT SIZE
PLAN VIEW 36 [q 2-ci
Distances and dimensions to meet requirements of H63
r 30W-EVERYTHING WITHIN 100 FEET OF SYSTEM
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I di_ a o~thl Arrow
Ii ENCHMARK: (Perm t reference Point) Describe:
Elevation of ver 1 reference point: Slope at site: ~I t
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover : 777, Tank manhole cover elevatio-':
Tank Inlet Elevation: Tank Outlet Elevation. `
PUMP CHAMBER
Manufacturer: /y, Number of gallons u
Number of gal. pump set r a cycle_ cc, gallons; total apac it y o
distribution lines1 . -gallon: sire pump ~-r head;
gallon per minute horsepower_ ra-name of pump
and model number
Type of warning device A, Alie,hf'o ~~ys7~ins 1,,,
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device -
SEEPAGE PIT SIZE: - um ems-pits ------T,ctt. ammeter
feet liquid depth-- seepage pit inlet pipe-e:Levation
bottom of seepage pit e evatron _ feet. r,
SI:EPAGI? BED SIZE: number of lines width leogth tit.e depth~,~
SEEPAGE TRENCH: zidth length -1 Pl?I:COLATION RATE AREA REQUIRED-~ REA AS BUILT
INSPEC' OR
DATED PLUMBER ON JOB
LICENSE NUMBT'R
REPORT OF INSPECTION - INVIVIVUAL SEWAGE {T'EM
Sanit.zrif 11 Fnm4 t
State. Sept4.e~
AME Town,5hip~ St. CAo-i x Countcl
oca.tc.un-_ ~ Sec.tion~Lo,t # --Subdivil6ion---
1_PTIC TANK
Size _ - --9aQe on's Numbers ob compaAtment,5
H~ ghwate.r
`tMPING CHAMBER
S.i.ze gaLkona Pump Manu6acturc.eA Modet Number
I.OIN~ LANK
St ze gaE.Eons Number- o6 CampaAtmente
Pumpe A---- - AtaA.m System
.5 tanee. 64om: WeU Buitiling 12%
e Lope
Highwater-
:;SORPTION SITE
Be.d Treeneh
htanee. fir.om: Welt Building-- t2% 'stape
HighwateA
SORPTION SITE DIMENSIONS
Wi.d,th o6 tAeneh At Requ_'Aed area 6t
Length oA each fine-_ -6t Depth o6 Aock befow t~k-e to
Number, obi Pt~eS__ Depth ob Aoo.k uve.A ti.fe in
TotaX t..ength o6 Unes-_ ___-{yt Depth o6 tite be. ow grade- ~.vi
04'etance between tines_ - 6t S.Eope o6 tA.eneh I.n. per 100 6t
Totak absoApt-Eon aA-e.a_- _-fit Type o6 Cove.A: PapeA on stAaw
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if OIMENSIONS
NumbeA o6 GAavek- around ptita yeb nu
Outs de d-i.ame teA 6t Depth below .tntet .t
Totak abborption aAea-_-- Ut
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AAe u Ae q u~-Ae d 6t
VS11 ECI1 0 By TITLE
i'PROVED DATE 19 &
JECTED DATE 19 B
IASON FOR, REJECTION
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E H 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: 1/4,__416!!~X, Section R1E (or) W, Township or Municipality-_ ^ S ~ ~
Lot No. , Block No. County
Subdivision am
Owner's/Buyers Name: ~O Mailing Address: (y LiC~ / ~c r e / Ll 57-
/ & lets 4 TC i^ X71 /!7 h`
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS 9 21 S"' PERCOLATION TESTS
SOIL MAP SHEET y NAME OF SOIL MAP UNIT
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 AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
C i- all 77 '
P- Z2 Z
P- l ► o /2ZV 33
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
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Y 37
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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 (2/5- ~~.IIndicate sole ~distances.
Give horizontal and vertical reference points. Indicate slope. .-e,
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the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods
1,
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) 16 A 4~ IZIZ L02 41Z /T_ Certification No.
Address 21 rkA '
Name of installer if known
A-Local Authority CST
State Permit
PLB 6 7 State and County
:dam w Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
't,~7 4 i!~7 2 Y6
.aIV, R E (or) W Lot# City
B. LOCATION: Section 2_f,_T31
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ,
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family L"' Duplex No. of Bedrooms -_25 No. of Persons
D. SEPTIC TANK CAPACITY la 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 Z'7J Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate '-6;- 6 Total Absorb Area - sq. ft.
New -Replacement Alternate (Specify)
Seepage Trench: f No. of Lineal Ft.. tJVidth j Depth Tile depth (top) No. of Trenches
Seepage Bed: Length t kcith1_2_Depth -Tile depth (top)- ~No. of Lines 2
Seepage Pit: Inside diamete- Liquid Depth No. of Seepage Pits
Percent slope of land _ S C> 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 S iI Tester,/
NAME ~/J , G- ' c~/ & Z,, /1 ) L, t.S.T. # and other information
obtained from
42 (owner/builder). Y/,-
Plumber's Signature P/MP~iSW# 7 Phone # ,7 y
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 Belowrr FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State County/ D -ate 'd
Permit Issued/Rejuted (date) f d /ff Issuing Agent Name
Inspection Yes4_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
REPORT ON INSPECTION OF SANITARY PERMIT #
(1 Name and Address of Permit Holder Person/Persons at site (2 )Date of Inspection
Name, ress, License No. o ns a ing Plumber Time of Inspection
(3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well:
M DOSING TANK: Manufacturer: # of gallons:
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute
horsepower ; brand name of pump and model number
Is the warning device installed? ❑ YES ❑ NO Wired? ❑ YES ❑ NO
;
8 HOLDING TANK: Manufacturer o gallons
construction ; depth to the cover ft; If septic tank is
being used are baffles removed? YES ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ NO; Wired? ❑YES ❑ NO;
Locking device on cover? ❑ YES ❑ NO; Diameter of vent and material ;
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TREN H: Total length of seepage trench ft; width ft;
tile depth ft; ft to well; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% falling away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO
(13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO
DILHR-SBD-609_5TN.ll5/80
Signature of Inspector:
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TRANSFER FORM
SANITARY PERMIT
State Permit #
PLB'67-T
Sanitary Permit #
County G
Sanitary Permit Transfer Date Original Permit Issuance Date Ze
A. Property Location: '/4 Section TI_N,R (or) W Lot # City
Subdivision Name, Nearest Road, Lake or Landmark BLK # Village
Township -
B. TYPE of Occupancy: Commercial Industrial _ Other (Specify)
Single Family X Duplex No. of Bedrooms { Variance
C. SEPTIC TANK CAPACITY 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/SIPHON CHAMBER4Z0_ Total gallons Prefab Concrete--I- Poured-in-place -Other (Specify)
D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area_sq. ft.
Newer Replacement Alternate (Specify)
Seepage Trench: No.Lineal Ft. Width Depth Tile Depth(top) No. Trenches
Seepage Bed: Length Width z
-Depth Tile Depth(top)42(L' No. of lines -i
2
Seepage Pit: Inside di eter Liquid Depth No. Seepage Pits
Percent slope of land l% Ci' Distance from critical slope--
E. WATER SUPPLY: Private ❑ Joint ❑ Community ❑ Municipal
Present Sanitary Permit Holder Phone No. Sanitary Permit Transferred To: Phone No.
Name ~r~~~ Name
Address Address
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I, the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with
section H 62.20•, Wisconsin Administrative Code and that I have sized the effluent disposal system according to the EH-115 prepared
by the Certified Soil Taster and/ y additional soil tests that may have been required.
Plumber's Signature MP/MPRSW # Phone
Plumber's Address
Information obtained from C3,,L (owner or agent)
PLAN VIEW: Provide sketch below of any revisions to original sanitary permit. Include direction of slope and all distances in accord
with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property or neigh-
'l has not been dri
41-4-
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lled Signature of Issuing Agent
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1. County (Yellow copy) 3. Owner (Pink copy)
2. State (White cony) 4_ Plumber (Green copy)
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