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- REPORT Of INSPECTION - INDIVIDUAL - L(WAGL SVSA
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StPTIC TANK
Size ✓_T~' --gaf-Zon.5 Numbers o6 eompaktmen,ts
04'
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Highwate.n
PUMPING CHAMBER
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M) 1 DING LANK
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A6SO.RPTION SITE DIMENSIONS
G11 dth. o f th.evtch ,t Requ4'hed ahea
Lcngth o6 each i.ne - ~c-~ Depth o6 Leoek bekow tc:4e in
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- - - OA Tf_ 19 x
R1 .11 C I 1 I) DATE 19 n
Rf ASON 1 0R RI JECTION
L B 6 7 State and County State Permit #
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:
v
B. LOCATION: '/~Section ,Zf, T N, R E (or) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
~eI~f~/~(
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family- Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 4QQ Q Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation x Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate- Total Absorb Area sq. ft. 767
New--Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed:- A_Length WidthDepth Tile depth (top) 42-4 No. of Lines
Seepage Pit: Insi e diameter Liquid De th No. of Seepage Pits
Percent slope of land 1, Q D E eW TESr,6W 4/?,C,4 Distance from critical slope .46o7- R F*-rc '
WATER SUPPLY: Private X 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 Certifi d'"Spoil Tester, _
NAME ,7i4~i yQ /C.S.T. # and other information
obtained from (owner/builder). 41
Plumber's Signature MP/MP_R #Phone
Plumber's Address COT.
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.
AT7r1Y 0&, - Xa OFu X,15 /Nl~
,Qty S'O'e BY 6' t?CPCSeD AS NoMr /10joy"
Ay - CAS7 Pii'~ ZeAO _ -TvlNLs
~ 3"Ton~,e= UNprR P I/
,u c3tAt PIPE ~pn„G &AL. SEPM, MVk
114 w .m ii Ph'rlC/Y'(r N67
Ta .S°ALF
.4r I
. m ALTERNAT
z _ . _ AR E ; PAR x~t~a ~.hES
t
N GASH ENrS p8orl E
Y
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application (p 1-~ 1 Fees Paid: State,/ e-0 County #g~ Date
Permit Issued/ Rejected- (date) Z. - 3CI -1~'/ Issuing Agent Nam
Inspection Yes A_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
_J
EH I 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 C '/4,S'/4, Section TN,RE (orIOTownship or Municipality
F~ JS M I T County T - CRO f/t
Lot No. , Block No. p
1~>~ C.~ujtc(i~is~on Name
Ow~nr's%Buyers Name: /7 [y~~/( IC / .1 /
r
Mailing Address: 1);) T'' I /y/Y/y - 1,I SG 67 Y
TYPE OF OCCUPANCY: Residence X No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS InCT PERCOLATION TESTS 0G'7~(-D 219
SOIL MAP SHEET 17 NAME OF SOIL MAP UNIT__801' BED C+~k CRSZ9 FD
` a pyiMum j'v TW IS
PERCOLATION TESTS AT r
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 RIOD 1 PERIOD 2 PERIOD 3
P-1 a F , 4 A/ 0
P- 2 fl A 0 '3 1
P- /#I r~ ld 0 2 I
P- If ii
S' -2 lof
!!r A /0
NI)
P
S
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-
B-
B-
72
B_ s ri r. ,,r1Vip
B- /I° /r
B- 'Ir
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the locate n and square 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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O Ut) nS N I a H D ~ EAST A'
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N
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- 407
A107 _ TO
5 LAN YA _4
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1, 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.
Name (print) Certification No.
Address WIS G
Name of installer if known
s
Copy A - Local Authority CST Signature
r At
9
3
ST. CROI X COUNTY
~r WI SC0 N S I N
a
ZONING OFFICE 796-2239
HAMMOND, WI 54015
June 20, 1981
Howard Mittlestadt
R.R. 1
Knapp, WI 54749
Dear Howard:
I am enclosing your copy of the PLB 67 as you
requested, for Phil Kemski.
Would you please make a separate plot plan on
a 82 x 11 paper and return it to us immediately.
We can not send in this permit to the state
without this separate drawing. Due to the fact
that there is a 10 day time limit on this re-
quirement we will need this from you immediately.
We will need two copies.
If you have any questions, please contact us.
Your truly,
Harold Barber
sl
Enclosure
Ability Business Co.
A ' B C Complete Sewer Services
KNAPP, WISCONSIN 54749 Phone: 665-2112
04 7~~I-Al-
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1,5
A C14,
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4Q p y~~ t ~~~rA~T r~~
Ts
_ v
Ability Business Co.
A ' B ' C Complete Sewer Services
KNAPP, WISCONSIN 54749 Phone: 665-211T
TocJN SN l OA D
7~' A IIfNTioN - N o i-Ya Ner W F/I
rl3fb s ToNk P ED ROOM /40m F
5ToA1E uND,xR PiPa
Z
Z ~i' dES/DE PIPE
-:2 D UER /P,F Y,•GAST PIPE
0;rAL 30" MANNo6F &NBEL°klG-RpDF
~ sroNF
- - " -Joao GAt. SEpTIC, T.4Nk
RED Q'/ f ~ ~ y,i GAST R/SF - LtAD ,N G,l J'
3 LINES - 3- y., VEA/T5 la' CAST fi ff
8f-,D To BE GuUERE,D 8 A
Y gie, qn fLAs7ec.
M A RsH HA y og ST~'AGI
8FA -SITS ay LCVEt AREA S of 1,0 ,D 1s i RjeJTAN i jN,E
6- RA P F A 94,
Q
0
o 40 Q 3 - Pt KFcRA7Fo 1 /NES
(PIAS-r rc)
$ I Q 3 - CAST UfNTs
~ ABouF F~Ni c1~ Eli
• ' 3i~, 90 fg' G RAGE W /FN STATE
A ffRodkp OF-A/T GAS'S
SuR~EYoRS pR~pF~T~
L►NF Po5F
DRAW IN& /VO T 7-0 SC,9 LL
,Ty - )46U)AR,D m irTt-,,~'SrAz)T
/Y\ PRSIA)
a~l~
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'/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:
k Al,
Property Location: / City, Village or Townshi : County:
t/a ~T~ NCR (VVJ -S `
~E (or). /I("+~ FILEZ 12
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
Le 7- 1 I r*, (If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required. I~Zl
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY 21L (s
HOLDING TANK CAPACITY
_LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
7_,!~ ❑ Alternative (specify) ❑ Seepage Trench
Water upply: Owner's Name as Listed on Soil Test Report (if other than presen owner):
Private ❑ Joint ❑ Public tji &
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: i P/MPRSW No.: Phone Number:
Plumber's Address: Name of Designer: _
IT7
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ APPROVED Sanitary Permit Number:
❑ DISAPPROVED
Reason 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-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Pi umber
DI,_.AR-SBD-6398 (N.03/81)