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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC.Z_,j/ N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION T LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
yERYTHING WITHIN 100 FEET OF SYSTEM
7T
E i
i
FT 1 11
I Ix
/ -
X di a e o th1 Arrow
I SC LE
BENCHMARK: (Permanent reference Point) Describe:;
Elevation of vertical reference point,: Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover : / Tan manhole cover elevation
Tank Inlet Elevation: 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 feet diameter
feet liquid dept seepage pit in et-pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines 1 width leytigthZ~ tile depth"
SEEPAGE TRENCH: width length
PERCOLATION RATE ? AREA REQUIRED AREA AS BUILT K
INSPECTOR
DATED PLUMBER ON JOB 1 , A
LICENSE NUMBERi
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SVSTLM
San, tazcy 1?e.hrnt
state sePti c r1 _
(IW
OAh,( p St. Cnu c x Cuuntc~
_ ,
So G(/ S uvc Lu t Sub divi,64"un
ga.Q.konb Nurnbeh. oA compa~Ltrne.nts
M: (clef Buieding 120 5~ope
Ilk' ghwa (o(
ri iCHAM6CR
gatton.S _ Pump Manu6dctuh.e.A. Mode4' Nurnbelc.
W i O I NG TANK
gattonA Numbe.n Q6 CompaA,tmen.ts
A.Ea&m System
P r,,kwc• (nom: „Wett Buitding_ 12% e~upe.
Highwaten.
A; ION SITE
I Trench
I. rovwc (nom: wett _ Building r2% 6tope
llighwate.n.
N `,III DIMI NSIONS
oh l ~cc ncFc At Requ.I.ne.d a.n.ea I
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t Depth o A ko c 1z below t 4,k e 4 P1
oA- k..LneAs Depth. o6 noch oven. ttiXe n
lo tak ke.ng-th - o 6 tines -,.--6t Depth o6 tiZe be_fuw q~Lade.__-`~- -.~.n
Uc a tance between f4,ne,6 -At Scope o4 one-neh _--------in. poll 100 t
lotae absonp,txon ake.a, -_.-.4t Type ob Coven.: PaptA on etnaw
c r 01 A4T:hIQI DNS
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p
i 6)v TITLE
0 DATE 19
DATE I •
I II CI10N
State and County State Permit # /~/-1716
PLB 67 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:
~i 4e!~~ i~,", _S /7
B. LOCATION: S / '/4 Section ZL, T,3/ N, R4a 11 (or) Vj- Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms _ No. of Persons ~j
D. SEPTIC TANK CAPACITY °)0 -Total gallons No. of tanks cam(
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement ,,Y
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 A Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length_ Width -Depth Tile depth (top) No. of Lines L
Seepage Pit: Inside diame r Liquid Depth No. of Seepage Pits
Percent slope of land- ~ft+ Distance from critical slope
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 Certified Soil ester,
NAME aAJA",7-%~ft+ ,S C.S.T. # and other information
obtained from tti.j:✓L%~ _ (owner/builder).
Plumber's Signature P/MPRSW# ki' 5 Phone
Plumber's Address rt.~ ~Gri t+,r9c] G 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 Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Pa}d: State Co my/ rrttOO Dat /
Permit Issued/R.efee4ed (date) 0) Issuing Agent Name
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
i
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
O. BOX 7969
LABOR AND C r
HUMAN RELATIONS PERCOLATION TESTS (115) -{yFAbl WI 53707
~O
LOCATION: SECTION: N/R (or) W TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. N F BDIV Qtl~1~ME: 17 11,3 Z C U TY: OWNER'S/BUYER'S NAME: AI NG ADDR S:
'e ja~NC 19i
1 -
USE DATES OBS R ONS M E
NO. IEDRMS.: COMMERC!AL DESCRIPTION: W Replace OF[ LE DESC 7 NS: ER COL TESTS:
X Residence F❑ New 4WReplace e
RATING: S= Site suitable for system U= Site unsuitable for system ? C
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING T NK: RECOMMENDED SYSTEM: (optional)
NS ❑u EIS ❑u OS ou o S ou ES ❑u I __71
-
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V. I If any portion of the lot is in the
under s.H63.09(5)(b), indicate: 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.)
B- 28 "
'op 27 > Y7
~J
a C.. .z i
B'
B-
13-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PE OD 1 PERIO 2 PERIOD 3 PER INCH
P- w
Al S7
P-
P _ J
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.
SYSTEMS ELEVATION ~f!(d
K-✓~,./Ml:~l fir,, /~.~I~`/J~14~4JC~. Gt.CA~' ..+W
't, .4V4'4'r1CW 01 44 10'
91
S0,4 &'eZd&.S )110ji'f.L 43M
~j TN
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:
14 ri)'d;
ADDRES : CERTIFI ATION BER: PHONE NUMBER optional):
42
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
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