HomeMy WebLinkAbout042-1078-95-100
AS BUILT SANITARY SYSTEM REPORT
OWNER ~c~~- TOWNSHIP ~~t//~L . SEC.-)_T W
ADDRESS Z4 ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
W-FIVERYTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: -/-j)// C Liquid Capacity: l r-r
Number of rings on cover Tangmanhole cover elevation:
Tank Inlet Elevation: 124 Tank Outlet Elevation: y
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 bran 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 depth seepage pit in et pipe-elevation
bottom of seepage-i pt elevation feet.
SEEPAGE BED SIZE:, number cj- lines width i,5~1lengt the depth 12
SEEPAGE TRENCH: width length
PERCOLATION RATE_ AREA REQUIRED REA AS BUILT
INSPECTOR f
DATED l C _ PLUMBER ON 0
LICENSE NUMBER - r,
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitary Permit ao 9
State Septic
NAMESD.A Z TOWNSHIP St. Croix County
LOCATION Section pRTLot Subdivision
SEPTIC TANK
Size 1 ~ gallons Number of compartments
Distance from: Well Building ! 12% slope- -
li i g h w a t e r- -
PUMPINGCHAMBER
Size gallons Pump Manufacturer Model. Number
ITOL D 1 NC TANK
Size gallons Number of Compartments
Pumper Alarm System
Distance from: Well Building- 12% slope
Highwater ~ - -
ABSORPTION SI'Z'E
Bed-~ french-- _
Distance from: Well Building _ L2% slope
- -
ilighwater
BSORPTIO-N S 1'E DIMENSIONS
f t Required area (~~-1 t t
Width of trench
Length of each line ft Depth of rock below the j
Number of lines Depth of rock over tile in
Total length of lines- ft Depth of tile below grade i n
Distance between lines L~ ft Slope of trench,~Z_in. per 100 It.
Total absortptfion area °{Z- f. t Type of Cover: PIT DIMENSIONS
Number of pits Gravel around pits yes no
Outside diameter ft Depth below inlet I`t
Total absorptio area ft
Area required _ ft _
1 INSPECTED BY T ITL E
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APPROVED DATE 98
REJECTED DA'L E' 198 to
REASON FOR REJECTION (lr~
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State and County State Permit #
PLB 67 Permit Application County Permit #
' - - for Private Domestic Sewage Systems County 0,e { ~
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
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B. LOCATION: j 4~7' Section, T N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# f`u<<I-L.>res Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family ' "t/- Duplex No. of Bedrooms 3 No. of Persons
D. SEPTIC TANK CAPACITY /4`-3-1%' Total gallons No. of tanks`
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete 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 ;2- Total Absorb Area i S sq. ft.
New - ~ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: 2 4 -Length it Width _Depth 16'" Tile depth (top) - No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- l 4 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 Testier, 141
NAME c f Yr c( C.S.T. # ) V P 3 and other information
obtained from (owner/builder).
z` Phone ~y~ - 5
Plumber's Signature _ L A-1 MP/ PRSW#
Plumber's Address - ~ • 4 i4~ vg za n7 ~ffl 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 Paid: State County" D O ' ~ -
Permit Issued/ftetu TSB (date) /Q 91 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
• DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
/Td?N/R 14 (or) W e IM
OUNTY: OWNER'S BUYER'S NAME: AILING ADDRESS:
C
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USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: R D TONS: PERCOLATION TESTS:
Residence NNew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system S'/h V ~LF tis
CONVENTIONAL: IMOUND:-GROUND-PRESSURe INSYSTEM-IN-FILL HOLDING dRECOMMENDED SYSTEM: (optional)
s au 0S ou [:]S ❑u ❑ s ❑u ❑ s ❑u
If Percolation Tests are NOT required DESIGN RA//TE: SYSTEM EE I If any portion of the lot is in the
under s.H63.09(5)(b), indicate: C-/Q 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- ,L - 7 7z _/~~-3 i-
B- 3 72 S-J j/ - y'y'= L.r3r-j
B- 1/ 72 3-/3/- E
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
3 1
P_ 3 i 4~
P- 2 3 ,
P- ~a~ r 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 3v 'Made in'3c6ofd with the procedures methods specified in the Wiscw sin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME( rint): TESTS WERE COMPLETED ON: j
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ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
}C //7 CST SIG TUBE:
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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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