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SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW-EVERYTHING WITHIN 100 FEET OF SYSTEM P _ V P 1 17 I di a e oath Arrow y S CAL- BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: ,,pp7 3`. SEP'1' I.C TANK: Manufacturer: f ~2 a Liquid Capacity : ~o Number of rings on cover Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons )kallber of gal. pump set or a cycle _ gallons; total capac it y o distribution lines _gallon: size oY pump ------,-head- gallon per minute horsepower _ brand 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: NumFer nd plts eet diameter feet liquid depth seepage pit inlet pipe-elevation-- _ bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines _!3 width length `the depth3c~'' Sl.EPAGE TRENCH: width length PERCOLATION RATE ~ AREA REQUIRED- A~ AREA AS BUILT -7c7 INSPECTOR DATED__ PLUMBER ON JOB LICENSE NUMBER q R1 PORT Of INtiIII CTION INDIVI'UUAI_ StWAGL -SVN-Ft M Savii ta~1it Poe 1to4 t ~p S to t,cp tc('14 NAM I Tow vthll; r) if((IV( S~ctiov;k'' Lot # S7)(14 vi6 iov( I I I ANK gael'oviA NUrn1,v~t of eornpati trnvntA. ti7trII,c A~(oIrl: Wvi,r 614iI'd~v1cl-- 1 12~, !1'oC>e----f- - H i gGtwa tv rt I'11MPING CHAM8t R zv ,jaeeoYtb Pump ManuAa.c.tunoll Modvk Numboji (W I_V I NG TANK S-i 7C IIafvovtb Numbest o, Comp.antrnevt-t~ I' n m p e rt ke a n rn S y,5 l e. rn r ti takicc Oom: Wvf't auif14,ng_-- IZo 5lape- H i gIIwa to n I I ON S I TC t; 1 . T ~1 e ri c It l'okice AIt(Irn: We Fe / Bit e .ing 92`0 topv - - - Htg hwa to ~1 I'I'f ION NITt VIMCNS'ION/S W( dtlt oA ttcvvtch Requ.i nvd alt-ca f crtgtit oA each f4ne (It Depth oA muck, below .ti.Xe- lc~j~ <vt Numbers oA Ki.neh Depth uA noe~h overt ti'6' o~ in -I' toe Pevtq.tit OA k4'.vt.V.6 A.t Dvp.th aA ti.fe below viade rvt intavtce b fwvvvt P4vteh -A .t Mope o6 xne.vteIt vt. pc 100 AI 3 ) 37 Iotat' ((bAoAp•N oh altea (It Type oA Coven: Papv>r 011 AtIfMA) I I U IMI NS I ONti ' i U t, rnb c 4 o A p.i t A G,i a v v P a n ('I u d r< t - 1I v vt 1 )trt-tii(I c d -ictrneterl At OvpIh be cow ivtcc.t (f~ IIrr(' (btionpt((rvt aIf ca A-t i A'ri'rl It cIt (11r1e-( A-t v 1'1 CH I U 6v TITLt I'I'ROV1 0, DATE 1I n I fI Cft1) DATE 19 b'I AIWN 1 0 R RC It CT ION DEPL\ATMENT OF REPORT ON SOIL BORINGS AND ILDINGS II+JDUSTRY, 0o~ Q.. IS ION LABOR AND PERCOLATION TESTS (115) 3707 , HUMAN RELATIONS (Mi4EiON, 3707 LOCATION: SECTI _ T MUNICIPALITY: LOTNO.:BLK.NO.'.s SJOWAA IIdFJ %T N/R ZEE (or) W L 7 ~ l ly V OV COUNTY- OWNER'S BUYER'S NAME: MAILING ADDRESS: USE ATES OBSERVATIONSIRW~ E NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: A ION TESTS: [12FIesidence ZNew ❑Replace 71fjf~ Z3 J'(/l(JL SeS ~9 -S~►~r,~~ s~.r ~o~,y ; RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILLHOLDINGTANK: RCOMMEND DSYS EM:(o~io aq 1) _ $Q ff ©S ON ©S DU ,®S ❑U 0S DU ❑ S ,©U If Percolation Tests are NOT required DESIGN RATE: SYSTEM ELEV. I 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- RAJ. 13- 2- 3Z B 13''x,.. 30 0. au -6y- f-F•f 0/P /1d 1s 74/5 S// Sy-e4 w4 s Yt rzwr e Z av cY vE S%vE 4~i4 LL - oe 2 FT. B- dA04W,'S( Jft 2-3 PA-04-0,j SS " V a- t- ,v C S B- 7z - > y- 13 pe. 13.J.-Cry e 1. -7 r4lh PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P_ 1 / Z Z is 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. tx Cicy ? 9 -1 SYSTEM ELEVATION 231 aPo, Zol ses. r ( NW for IeOA3 r3/41 P E . PR~i I A / h t i'S Sfrr~+P 30, f e. 9 LAN _ 1VOZA Lo7' o J~ ' , 193 60- -10 L i,VE, IF 7P_ 9/Efl ` o P3 F ?'PACE' d r 19is' PI o#,n, L 65 1 1, 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: / If AP/ ADDRESS: C~TIFICAI,OJNnU, NUMBERT-HONf. NUMBER (optional):_ CST NATU7E.- ~ T~/lam Q ~~ff ~ f~i~~~• ~~'l~l~;T/~f • ~C DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) I State and County State Permit # s PLB 67 Permit Application County Permi # 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: B. LOCATION: '/4Section , TZ2 N, R 2UE (or) W Lot# -7-- City Subdivision Name,, nearest road, lake or landmark Blk# Village Al'IfI vIeko Aw5 ~Gi9/~t✓I!!EW ,P.. Township C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family X Duplex No. of Bedrooms No. of Persons 2- AVOL7> D. SEPTIC TANK CAPACITY /lTd_ Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete X 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~T~-Total Absorb Area sq. ft. New X_Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length 3S Width Depth `-Tile depth (top)-No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land_ -39.1 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 Tester ,e NAME 00b&& r NAME `C C.S.T. # 5 aaY(?Z and other information obtained from (owner/builder). p~ Plumber's Signature - / Phone #71-4 2- (P.5 l MR/MPRSW# Plumber's Address '722 DA 6F> Q }f U ~~,t~ 601,37 y014, 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. 0'~ ~ A Q ~Q !5A1 &7- 7Y A, 4 I, R Po/mar. i R POO E Rio l fob r 131 r Pl ' Oo c o o auk goc c Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY / Date of Application Fees Paid: State County d'v ate Permit Issued/Rejtr and (date) & Issuing Agent Name Inspection Yes X_ 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 Abb, - - AM ()/"-W 14nolf 11Eilv ~SG1-, lvT ;~eZ pGA/iUU/Ew ~4c~Es y 9 PEA N v ~,P ~oAv - ~~~EL ~c ZOT I ' ~ i ~gy f~UD o so s o~ _ P w M, p~oPosE1' o htOS _ - ~ o a~ V,POpOS~D i gn in -a + i ,S6 j ~~f J L0~ W uj I N oR V1 zn p ~ + I CJ S.~E 3 1 oR 79 to w- er i 1.'