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• AS BUILT SANITARY SYSTEM REPORT
TOIMSHIP SEC. - T, _N, R I W
•0t ADDRESS ST. CROIX COUNTY, WISCONSIN.
-3DIVISION , LOT LOT SIZE 3 ~ d V V~ V~)
PLAN VIEW
-Distances S dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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Indicate North Arrow j j
SCALE ' - I--
tPTIC TANK(S) MFGR. CONCRETE 1' STEEL
NO. of rings on cover Depth DRY WELL
►ENCHES NO. of width length area
no. of lines width length area
depth to top of pipe
a6REGATE
?.'W RATE AREA REQUIRED AREA AS BUILT
lisclaimer: The inspection of this system by St. Croix County does not imply complete
.o~pliance with State Administrative Codes. There are other areas that it is not possible
,o inspect at this point of construction. St. Croix County assumes no liability for
ystem operation. However, if failure is noted the County will make every effort to
,jtermine cause of failure.
,TEASES AND ,OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
`INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER
i-q WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES
Division of Health
Section of Plumbing & Fire Protection Systems
ON-SITE WASTE DISPOSAL INSPECTION REPORT
Name of Premises
Street City County
Master Plumber Address
Owner Address -
❑ County Permits _ El Appropriate State Permits
Type of Building: El Public ❑ Single Family or Duplex
CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM
Building Sewer ❑ Conventional Soil Absorption System
Septic Tank ❑ Conventional System-in-fill
El Holding Tank ❑ Alternate Mound System
11 Seepage Bed ❑ Holding Tank
El Seepage Trench ❑ Seepage Pit ❑ Experimental System
BRIEF, FACTUAL COMMENTS AND SKETCH:
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❑ SEE ATTACHED
DISCUSSED WITH PLUMBER ( 1 Yes ( ) No SIGNATURE (Voluntary)
DATE OF INSPECTION
Signature of Inspector
White - Inspector Yellow Local lr,pector Pink - Plumber or Responsible Party
z REPORT OF' INSPECTION INDIVIDUAL SELVAGE SYSTEM
San.i.tany Penm.i.t
Saxe Septic
NAME rownsh.ip S~. Cno.ix County
Location Section
SEPTIC TANK
Size gattonb. Number o6 Compan.tmen.ts I
I
DiAtance Fnom: We.L.C it. 12% on greaten ztope - it
Bu.i.td.ing it. Wettand.d ~ .
DISPOSAL sysrEM Nighwazen - it.
.
Distance Fnom: Wett .12% on greaten ztope
Bu.itd.ing it. Wettand.d Ft.
• H ighwaten it.
FIELD DIMENSIONS:
Width o6' trench ' it. Depth o6 rock below t.ite ,Z_ .in.
Length os each tine ~ it. Depth ob rock oven .t.i.Ee .in.
Numbers o6 tines Depth of .tite be.tow grade kn.
f,
Totat. .length o6 tined /'L- it. Stope o6 trench in pen 100 it.
Distance between tinez=_i.t. Depth to bedrock it.
Tota.L abb onbtion anew - 6t2 Depth to gnoundwaten ~ .
Requ.ined area it2 Type of Coven: Papers on Straw
PIT DIMENSIONS:
Numbers o6 pits Gnavet around p.itd yez no
Outside diam eten it . Depth b et ow .inZe.t 6.t.
2
To#a.L absonbtion area it
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Area nequined it2 rn
INSPECTED By TITLE
APPROVED ,DATE 197 ,
REJECTED DATE 197.
l~ `
EH 115
WISCOMSIN 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: k 1/a '/4, Section , T ON, R) i (or)( Township or Municipality sx
Lot No. Block No. -County S~(
Su division Name
Owner's Name: /N~
Mailing Address: RX r/ S~~~`/ &)A TYPE OF OCCUPANCY: Residence K No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT X
DATES OBSERVATIONS MADE SOIL BORINGS- PERCOLATION T STS
SOIL MAP SHEET SOI L TYPE 4,-, c ,r y C'~ "I
PERCOLATION TESTS
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER SOIL SINCE HOLE HOLE AFTER INTERVAL
UM- INCHES THICKNESS IN INCHES
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P_ 3
Are r-
;Z y O / ~,2 Z /j
P Z Y~" Sep, /
/~t/o c) 14 11f
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
I
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- C21 e t5 2
All
B- > ell #
B-_3 ;77
of _~2
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square eet of suits a areas. Indicate nympep of square feet of absorption area
needed for building type and occupancy. Indic4to scale
or distances. Give horizontal and vertical reference points. Indicate slope. S/1tr_111r1y fAe_lA.A
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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
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 belie .
Name (print) Certification No. /4 s
Address_ ! Cvr f✓ ✓ ad, 0
Name of installer if known S~r X
(ev
CST Signature
COPY A -LOCAL AUTHORITY
PLB 67 State and County State Permit #
w Permit Application County Per ffiv#
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: 7(L7 '/a, Section 3& T j~>N, R_a E (or) ) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
.
Township Si,
C. TYPE OF OCCUPANCY: *Commercial *Industrial "Other (specify) *Variance
Single family X_ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY JQL?r') Total gallons No. of tanks f
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.,- '~Total Absorb Area 6;, sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: _X_Length _,Width-Cs?Depth 1721-" Tile depth (top) No. of Lines -3
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private IX 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,
Z1 C' %%i/.lt,Xj! -G ,SSG- fd C.S.T. # ~ -/~XL and other information
NAME i2ijVA
obtained from L= caner builder}.
Plumber's Signature ~rri~ MP/MPRSW# :ZYZ Phone Z",
Plumber's Address
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 _SE ONLY
Date of Application Fees Paid: State /-6- e,0 Count Date 0 -2- ZZ C
Permit Issued/Re~ge#td (date) U Issuing Agent Name ?
f
ection Yes No State Valid# Date Rec'd
ty (whits copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
nk copy) 4. plumber (canary copy)
Revised Date 7/1 /78