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~r AS BUILT SANITARY SYSTEM REPORT
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TOWNS CIP i SEC''
WNER ,
ADDRESS r ✓ ST. CROIX CO TY, WISCONSIN.
8U. DIVI'SION"`,a. LOT LOT SIZE
PLAN VIEW
"stanpes and dimensions to. meet requirements of H63 z
A, QW EyEUTHING WITHIN 100 FEET OF SYSTEM
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I di g o th Arrow ' ( '
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wr= .B,~NCHMARK: (Permanent reference Point) Describe:
h~ eva ion of vertical reference point: Slope at s
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SEP'TIC `TANK: Manufacturer: / , Liquid Capacity
~~a N mber of rings on cover s.... Tank manhole cover elevati.on:
~T
w , • Tank Inlet Elevation: Tank,Out11et El.evat an
P CHAMBER
= ,Manufacturer: Number of gallons
Nurnlaer of gal pump jiet or a cy! cue- gallons; tota~apacity, off-
dis`tributian lines gallon: size o pump head, k'
:l'• gallon per minute horsepower _ r'an name of` pump'
4Y, and-,; model number
r <:'Type of warning device
O.DING TANK: Manufacturer Number of gallons
'Elevation of manhole cover
; ~-Typpe of warning device
Y~ SEOA+GE PIT SIZE AumFer o p is eet amete~' '
feet liquid dept seepage pit in et pipe-elevation
bottom of seepage pit elevation feet. { SE9PAG ' BED SIZE: number of linesw w
t ~leftgth ile d ptl i,
id'
S99P•AGE TRENCH: width lengt x_
PIiCOLATION RATE t.
> INSPECTOR _
PLUMBER ON B ,
DATED <
LICENSt NUMBER
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AS BUILT SANITARY SYSTEM REPORT
TOWNS IP i SEC2~-B"
. OWNER
'ADDRESS ST. CROIX CO TY, WISCONSIN.
SUBDIVISION (L OT LOT SIZE
PLAN VIEW
Distances and dimensions to. meet requirements of H63
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OW EVTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe: ;r Elevation of vertical reference point: 5 1ope at side
SEPTIC TANK: Manufacturer Liquid Capacity' Number of rings on cover Tank manhole cover elevation: L.''
Tank Inlet Elevation Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons _
Number of gal. pump set or a cycle gallons; total capacity ate.
distribution lines gallon: size o pump- head;
gallon-per minute horsepower ;bran name of pump
and, model number
Type of warning device
HOLDING TANK Manufacturer Number of gallons-
Elevation of manhole cover
~'Typpeof warning device
SEEPAGE PIT>SIZE: um er o pits _ eet iameter _
feet liquid dept seepage pit inlet pipe-elevation-
bottom of seepage pi e evation feet. A~,_
SEEPAGE BED SIZE: number of lines w_ th 4 _lei,tgth the depth___'
SEEPAGE TRENCH: width length
KREA REQUI D ,L'', EA BU LT _
PERCOLATION RATE;,
Y, INSPECTOR
DATED s= f~ PLUMBER ON JOB r ~t--~r
ILI ' LICENA NUMBER -
REPORT OF INSPECTION - INDIVIDUAL Sl-WA(.,'E- SySTI M
San4TaAy VcIt mi t a(~,~'~
S to to Septa?~!G9
NAMI Township St. Croix Counts)
I oco r (on j of Sectiono?SLot Sub it,4,s con
tiLVI IC TANK
Si ze 1 ~ ga tons Number oA eompaAtmen-ts
f)i b lance {nom: wets Bitif-ding__-/-77 12% 6 cope - -
Highwa,te.4
I'UMPING CHAMBER , r
Size gatton~u anu6ae.tuAeh M0 deX Numbe'z
HOLDING TANK
S. ze ga to 1Nb oCo mpaAttmen.t:h
Pumpe,4 W Am Sy6te.m
04.s tanee Aom: We f Bu-i~dtin 12 ~ tiro e
Highwaten
ABSORPTION SITE
Bed ~C Trench
Ut-5 Lance 64am: Wets---- Bui Edi-n 9- / 12 n I oL,e r
HighwateA
ABSORPTION SITE DIMENSIONS
Width o 6 tAeneh ~t Re qui qed area - ~ r
Ievyth oA e.aeh Yine_ -S , --6.t Depth (16 each bcE'ow tiYe in
NumbeA oA ft'ne's Depth o A nosh oveA ti fv j t o
lotaf kengzh oA f.in.ea _ At Depth oA tlfe below grade
Distance between fines-/ _ t SFope oA IAencit - - (Vt. t)clf 100 Al
ption aA.eu ht Type v{ Covet: Pap eA A n tI,1(
I'17 DIMENSIONS
NumbeA a6 pti ~ a ef' ound pity yep - nr
Out3ide d. ame,ten -t D ptit below cVtec h
Total absonp-ttion anew - - l
AA.ea AequiAed- - t
INSPECTED By a ~IIL1
APPR 11 VrD DATE
RE JE CTED DATE 1 9 n
RFASON FOR REJECTION
P L B _ r 6 7 State and County State Permit #
~
~r 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. pOWN R F PROPERTY Mailing Address:
B. LOCATION: Section T N, R P-") W Lot# City
,17 S
Su Sion Name, / nearest road, lake or landmark Blk# VaLaa
Township
VVV [F
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C. TYPE OF OCCUPANCY: 'Commercial 'Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 40 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete t~Poured-in-Place Steel Fiberglass Other (specify)
New Installation L---- Replacement
Lift Pump Tank or Siphon Chamber Total gallons P efab 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 Tr nches
Seepage Bed: Length Width Z~"?--Depth-''Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- ' Zz, Distance from critical slope
Z
WATER SUPPLY: Private 2-Joint ❑ Community ❑ M icipal ❑
Owners name as listed on EH 115 if other than present owner:
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 syste,
by the Certifie oil Tester,
NAME C.S.T. #
obtained from
(owner/builder). -
Plumber's Signatu PRSW# Phone #4d-6 40
Plumber's Address #1 Z
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
ate of Application Dat ,A0 Fees Paid: State Count - Q -
ermit Issued/Rejemrd (date) Z,5L ~f Issuing Agent Nam t~
ection Yes No State Valid# Date Recd
ounty (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
to (pink copy) 4. plumber (canary copy)
Revised Date 7/1/78
INDUS
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
NDUSTRY, , DIVISION
LABOR BOX • HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
LOCATION: SECTION: _ TOWNS HIP/Mb1P+fel•P*EffY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
se /uJ/ zS /TAN/Ru'E ~-Ro~r //vvc ~crs
COUNTY: OWNER'S BtWE44*+AVlE: MAI LING ADDRESS:
CKO~x- Pf f t "outer s- -~cl UL{~..
USE DATES OBSERVATIONS MADE
NO. BEDRMSMERCIAL DESCRIPTION: New ❑Replace I PROFILE TONS: 1PERCOLATION TESTS:
%Residence
1 -3
t Z 3 l 8 Z 3
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM -IN-FILLHOLDING TANK: COMMENDED SN~kTEM: I~JS ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑ x as "S e5r~,
If Pe#H63.09(5)(b), on Tests are NOT required DESIGN RATE: SYSTEM EL
n of the lot is in the
4 If any portri
undeindicate: Floodplain nd
icate Fleodplain elev ion:
PROFILE DESCRIPTION
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF 'FtOIL WITH THICKNESS,. LOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF O ERVED (SEE ABBRV. BACK.)
B So 1 b\ S ~e1v~ 7 9D k_~h s z I i s t7 l v s~1C.H r Grist UO-) 7
B Z J b 1 ~O S 7 / ~6 T811 517) i& cs
w/S ~16/fT L b
B- 3 9Z you (f 7 9Z ~r ,tc t/ / t5; 1/
B- L/ S ~ 1C)0 1/ ' 9(3 1/ ,WSJ
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD z PERIOD PER INCH
P_ 1 V8 1s?,o 6 " G-ki t:_~ !/v Liss ) f7 /,u L,7"-C_ < 3 _
P_ Z V ~ 5w4EurA,c L 3
P- 3 S C~ cz_~a t~S 1f &3.o9 CS ll le-ft 1 < 3
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.
SYSTEM ELEVATION
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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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
~CJu`T 7. F C_C~~r~JC)i7~°}t 5-) 6 7ls- 2-3'-93 '
CST SIGNAT E:
IBUTION: Original-Local Authority, 2nd page Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
SBD-6395 (N. 03/81)
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