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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC.~~!tN-y
ADDRESS ST. CROIX COUNTY, WISCONSIN.
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SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
OW-EVERYTHING WITHIN 100 FEET OF SYSTEM
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All
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BENCHMARK: (Permanent reference Point) Describe :r_=-~tw~~fi~~
Elevation of vertical reference point: Slope at site: S Q
SEPTIC TANK: Manufacturer: - t~Liquid Capacity:
Number of rings on cover an manhole cover ele ation:
Tank Inlet Elevation: ~L Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle- gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower ran 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 eet iameter
feet liquid dept seepage pit in eft pipe-elevation
bottom of seepage pit evation feet.
SEEPAGE BED SIZE: number of lines ~wi th _ length tile depth
SEEPAGE TRENCH: w th Ieng h -i
PERCOLATION RATE & _ REA REQUIRED RE AS BUILT
INSPECTOR
DATED PLUMBER ON JOB 'r
LICENSE NUMBER j ~l "
RI`VORT•01 INSVICTION INOIVIOUAL SIWA(;L SVIMM
S it vii t it h rI I' c I rn t r
Stare Se 1.) 4C
IAAl I - _TownAh t.p --St. CAu r x C(I ((vr tq
( ((t i nv(S _Se.c.tion~ Lot H Sit bd4 vIt.A 4"o Yl
I I'I IC LANK
V yaf Panb NumbeA o(I eurnC)ah tmen,ts
1 rrrr(, ~ c A 'rurn: Clef 4-- - - 6 u.(' Ydi,,nrl--- = ~ ~_12o eeorv -
H.i ghwa to A
,IMI'IN(; CIIAM6_1 R
tii 'IV _gaxf onA Pump Manu(Iac-tu)l.e-A Modek Number
!GOING LANK
ti; re _ gaffon.s NumbeA oh Compa4tments
1 (I mf,r A Atahm SyA .tem
r tanee 6Aom,: We.kf Bu.i-eding 12% Akope
H.ighwaten
'WIWPTION SITE
Beds;' Tke.neh
r 5 tanoe Wet.e_ J BuitdZng r t2% 6Xope_
Highwa.te.A
~0 P1ION SITE DIMENSIONS
W4'dth o6 t4ene.h - At RequiAed ane_a
Iepi It tf( i.6 each f.inelC~ 6 Depth a6 Aoek beYow #cke in
Numhv ( o6 Y.i.#(ee Depth o(I A.oe.h oveA tl('4'e <v(
fn rax een9th 06 f.i.ne.e
At Depth o6 .t.cl-e below ynade_-o~. ~ 4 n
f
Din tanre be twe-en Y.<nee J {I t Vo!pe o~( t A e no h
4Y, pr~n 100 At
~I1r~l4 ab~o)(JA4,on aAea At Type o( CoveA: Papers oA Athaw 11 D I MI NS IONS
1 l2~
Numhv A o6 Pi t'6 Gk avvf aiv d r),(t6 yeA no
Outoidry diame.tetL At Depth beeow 4nect r
Total' abAoAptt'on aAea {~-t
An(a ney(t~Aed ~ h.t
NtiIII C I f U BV TITLI
I'I'ROVI U W 19 x
I 1 1 C I I U DATC 19A
'I AlWN I OR RI JECTION
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State and County State Permit # 7v
PLB 67 "1,,,, 1 -il
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:
4
B. LOCATION: % Section T"L N, R1L (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township <))IA17CAI
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family _X Duplex No. of Bedrooms - No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete d Poured-in-Place Steel Fiberglass Other (specify)
New Installation 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.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: _X_Length yL '-Width ~ / Depth Tile depth (top)No. of Lines 1
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 7 ,l 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 Certified Soil Tester,
NAME
C.S.T. # and other information
obtained from zp 1) (owner/builder).
Plumber's Signature MP/MPRSW# Phone #1~/,.
Plumber's Address ^ Ali X11, A'/v
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 FOR COUNTY AND STATE DEPARTMENT USE ONLY /G
Date of Application ~G Fees Paid: State County ate
Permit Issued/Rejected ( e) LG Issuing Agent Name
Inspection Yes No State Valid# Date Rec'
1. county ( ite copy) 3. owner (green copy) DIVISIO OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
IH..1ORev.9/7$
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: gib, '/a,d(LSection _,T=LN,RLL (or) W, Townsjiip or Municipality Z -~,i/ 7, IAI
Lot No. , Block No. Subdivision Name County S 7 '~G' a~
n `
Owner's%BuyersName: r )AA,i-Z_
Mailing Address:- - _ Z7 i4' G i
TYPE OF OCCUPANCY: Residence-No. of Bedrooms COMMERCIAI
EFFLUENT DISPOSAL SYSTEM: NEWREPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS :~Z- _ PERCOLATION TESTS T -'y
SOIL MAP SHEET Ile K2 ~ NAME OF SOIL MAP UNIT ~wx'~.~L:*i~r - S ~trr~ ['/~.~ir
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE OLE AFTE INTERVAL MIN; IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
Mnjlj~
P- 7 I~ li
P- t 3
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-
B- 7
B- T , S
B-
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I" A 7. X .4 2 C'A'
ds
B- t
Z' 11) ? - ?
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plane location 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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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) t")J: ZA'S Certification No_ S: > > /
Address -
-Name of installer if known 6- ~JIJIA
Copy A - Local Authority CST Signature
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