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CROIX COUNTY, WISCONSIN. - LDIVISION , LOT LOT SIZE ZDD'6 ' NUJ Ctihz~~cc~c..Q PLAN VIEW -Distances & dimensions to meet requirements of H62.20 - SHOW EVERYTHING WITHIN 100 FEET OF SYST4 /k,/~ a. - j- - _ - , - f ! I i f - 1 14 i r- - j 71 y I 1 A i - - =I 14 - ' - i I 4 1 indicate North"Arrow j i ( i i y S CALF *PTIC TA X,(S) C>C, MFGR. Q_ S j!!: > e, CONCRETE STEEL NO. of rings on cover Depth DRY WELL 'r*.NCHES NO. of width length area j no. of lines ~ ` width length G• area depth to top of pipe_ zt-) 6REGATE 0 A /Z 1~ (I r:_ _ ?C; RArE _ AREA REQUIRED AREA AS BUILT ksclaimer: The inspection of this system by St. Croix County does not imply complete ,n:apliance.with State Administrative Codes. There are other areas that it is not possible io inspect at this point of construction. St. Croix County assumes no liability for vStem operation. However, if failure is noted the County will make every effort to Ie~ermine cause of failure. CEASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. '-INSPECTOR DATED PLU:BER ON JOB LICENSE NUMBER i 1 I l~ r z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM t Sanitary PvLm.i-t State Septic- NAME NAME i ownzh.ip St. Ctso.ix County Location, Section , -P _ i SEPTIC TANK ~j Size / gatton6. Number o4 Compartment6 j Distance From: Wett St. 12% on greater stope it Building it. Wettands ~ • Highwatetc ~ it. DISPOSAL SYSTEM Distance From: Wett 120 or greaten 6tope St. Bu.itding it. Wettands Ft. H.ighwater it. FIELD DIMENSIONS: Width o6 trench it. Depth o6 tc.ock below tite in. Length o j each tine it. Depth o6 rock oven t,i to .in. Number o6 tines Depth o6 tite betow gradein. Tout Length o6 t.inez 6t. Stope o i trench in pen 100 it. Distance between tines it. Depth to bedrock it. Tout abhotsbt,ion area 6t2 Depth to groundwatetc it. Requ.itced area it 2 Type oi Covets: Papetc or Sttsaw - PIT DIMENSIONS: Numbers o6 pits Gtsavet around pits ye.a_____no f, Outside d,iamet ~ it. Depth betow .intet it. 2 Total absorb/.ion area it A Area required it2 INSPECTED BY TITLE APPROVED , DATE 19 7_ REJECTED DATE 197. r EH i 15 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH - P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION:` _ %,Section, T4f N, R1&(or)C Township or Municipality ' C'-, Lot No. ( , Block No. C 5M Q113 Ap County ,'ix ~O Subdivision Name Owner's Name: i L%1.~~11~ E?f~/~'✓Sc?)/Z,` Mailing Address:,/3/ _57r TYPE OF OCCUPANCY: Residence C No. of Bedrooms _3 Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS' SOIL MAP SHEET SUILTYPEyI%itr//f~dy PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL NUM- INCHES THICKNESS IN INCHES MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 r' P- ~ 74 Al u t J~ -3 me .3 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) 1-7 B-/ [[IiL~i L- ,rc~"~`~, l ) " S~ L J J [t ~~'1 Ca r~+ PLAN VIEW (Locate percolation tests,soiI bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate nu er square fee of absorption area needed for building type and occupancy. " ` Indicate scale or distances. Give horizontal and vertical refer %e p s I icate slope. t I l e. ~ s { /CIO 1 I P t _i z i ' S ST w _A_ j 14, I I I, the undersigned, 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) Certifcation No. Q Cdl S =p C, C, Address j r C Name of installer if known A, CPA V-> CST Signature 19 COPY A -LOCAL AUTHORITY PLB67 State anCounty State Permit # ~ . Permit Application County Permit # for Private Domestic Sewage Systems County f-- *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Ahif 40 B. LOCATION: S~v Section T N, R E (o0 ( Lot# -/City Subdivision Name, nearest road, lake or landmark Blk# Village Township A C TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance _ Single family Duplex No. of Bedrooms No. of Persons 2_ D. TYPE OF APPLIANCES: Dishwasher -YES NO Food Waste Grinder YES~><NO # of Bathrooms- Automatic Washer "YES NO Other (specify) 1200 SEPTIC TANK CAPACITY- Total gallons No. of tanks _ *Holding tank capacity Total gallons No. of tanks New Installation ~ Addition Replacement_ Prefab Concrete- 'Poured in Place Steel Other (specify) Y! FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 0 2)_3) /-Total Absorb Area _-esq. fcw~ Addition Replacement *Fill System ,seepage Trench: No. inf Feet Width Depth Tile Depth _ No. of Trenches ell epage Bed: Length Width Depth 112 Tile Depth- ~6 No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, ',`visconsin Administrative Code, and that I have sized the effluent disposal system f-crr) the Fly 115 prepared P-)y the Certifi Soil Tester, i`,`AME 1 C.S.T. # and other information htained from 06& C !L! (own builder). l ":umber's Signature P/MPR Phone - 2 - Plumber's Address 7 &a k /U. a L PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). E r-- t - /U`r k 1.' Il? RQ~ g u~ Do Not Write in Space elow FOR DEPARTMENT USE ONL - / - Date of Application - Fees Paid: State L Coun y Date Permit Issued date) Issuing Agent Name-~' Inspection Yes 1 No Valid# Date Rec'd., 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) -