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HomeMy WebLinkAbout038-1072-30-000 (2) Y ti 0. p 3 C) O Z. O a ~ `p it ~ a) ~ C lp I N p N U Q O E co w C Ln ' O 0 Q , Q n = s ca C: Z ow C _0 N L a5 LL o p)~ o a E Q U ° CL 3 M Q z y o O z n M w! a co F- z o o U o z L) v ~ ~ o N d z ~ - c o cn I- a) z c E -o co Cl) ww rn :n o- of a) E c a~ N o. ~ = o O O o tea' w z co z z o N z r_ -0 i N \T Co E C N N CL c-, N a `v Q CN CD 7 U O Z o (n a r- r- N to J U cn m 0) I>D E L v o q C) ~1 - nWD. I 04 M (n a) 2) _ ap ~ ~ Q (n Q I p Q~ Y cn U) U) O O 3 N N C r+ O p O E CA oM ai a o = n rn r C Co U) CV M ~a7 N v O r~ 'm p c m c W O d y N to z a) .p M N d o E c s try~'j M I~ N "C O 00 O w Co p •M o • O ~ Cn Q O Cl) Z_ 2 H fn O ea y Y ^I V ~ 7~ aII', a u c c d A U a~ I'' O N U Parcel 038-1072-30-000 09/14/2006 03:57 PM PAGE 1 OF 1 Alt. Parcel 17.31.18.301 C 038 - TOWN OF STAR PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - ANDERT, CRAIG A & LINDA M CRAIG A & LINDA M ANDERT 918 214TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 918 214TH AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 2.040 Plat: N/A-NOT AVAILABLE SEC 17 T31 N R1 8W 2.04A IN NE SW LOT 4 OF Block/Condo Bldg: CSM IN VOL II PAGE 403 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 08/14/2000 628081 1534/119 QC 07/23/1997 1095/472 WD 07/23/1997 839/498 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/18/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.040 32,200 136,300 168,500 NO Totals for 2006: General Property 2.040 32,200 136,300 168,500 Woodland 0.000 0 0 Totals for 2005: General Property 2.040 32,200 136,300 168,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 114 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 7u -9L4 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ~y\ HN1110011bII11 - ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 a August 30, 1994 Allan Cowles J Century 21 700 19 Street S. Hudson, WI 54016 Dear Mr. Cowles: On August 17, 1994, an inspection was made of the septic system located on the Richard Hustad property located at 918 214th Avenue, Somerset, Wisconsin. A water sample was also collected and sent to the laboratory to determine the level of nitrates and coliform bacteria in the water. The test results are enclosed. The onsite inspection of the septic system was a surface inspection only and did not involve physical excavation of the system, chemical analysis, or soil testing. Accordingly, there may be hidden defects which were not discovered. I was concerned at that time about the location of the drainfield, as it appeared that the garden was in the area of the drainfield location. Upon investigation of our records, the inspection report from the system installation was found. I returned to the property on August 29, and verified distances, drainfield and tank locations, and determined that the garden is directly on top of the drainfield. This is not a recommended use. I found no evidence of failure, however, I cannot warrant or guarantee that this system will continue to function properly in the future. As long as the system continues to treat and dispose of the wastes generated from the house, it's continued use will be allowed. Should you have any questions, please contact me. Sincerely, 40 V Pee_ Mary J. Jenkins Assistant Zoning Administrator cc: File COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 C3:Aw ~4~ 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 'iA'OIX CITY GOV.CTR CARMICHAEL ROAD ON, WI .TION: 918-214th Pv, , .-ECTOR: M. Jenk. i n-~' COLLECT I# 8-1-7-94 10 COLLECTED« 2t(*Pm cb :0E OF SAMPLE: Out i de faucet RE '[VEO ANALYZED:8-18-94 A L" Ih 2 9 lg'34 ANALYZED.2.00pa, STS C~JPi7'r' Aj ;FORM,MFCC: 0 flop mi ~ 'O+IlNGt?FFIC= ::C,'PRETATIOW Bac 3 OF.\NDEPENOFNl Ipproved Lab No. ~ o O P D a ~ d S PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTYw ~y WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmicha©{ Road Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during :inter months, making access to the home necessary. Please make arrangements with this office to insure that entry c.-n b(- ~~.Wa!er (VOCIs) _$185.00 El Septic :D Water (Nitrate & Bacteria) 45.00 0 Nitrate & Bacte:_ retest $15.00 Requested by: dress: _ Address: - A X01 cy S a, Y ~i . c ~L' j ZIP _:!1y(_;,f ZIP lephor.e NY: (,es) Sy' Telephone N2: Property address (Fire W & Street) rJ L=JCat1Cn: / `~L. i Sec. s~ R ~t W, TOFlII of >I~~{f fX21!~~1~.- R_a1ty firn:0 t ! Lock Box Combo: Closing Date: EN S- i TO BE COMPLETED BY PROPERTY OWNER ;tPROVID E A. SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Water sample tap location: Is the dwelling currently occupied? Yes ❑ No If vacant, date last occupied: _e of septic system: Septic tan}: last ,pumped by: Date: r Previous OZ,nerls Name(s) t~r~~-'~'/ y1~i Cr"5• -ve any of the following been cbserved? ❑Yd Slow drainage from house. ❑Y Sewage Back-up into dwelling. ❑Y1 Sewage discharge to ground surface or road ditch. CtY Nq Foul odors. 07-her ~Qn~r.Nents relative to system operation: i_ 7J ce,,t~f that the above information is complete and true to the ~g best 6f knowledge. OWNERS SIGNATURE - j DATE: ! • R C ~'~~i, F O1vNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION M St n~i ~ t, 1 ~I TO BE COMPLETED BY INSP CTION AGENCY System design &/or permit on file? Ves ❑No Sc---! series per SCS Soil Survey: sheet r e of soil absorption system: UBelow grd ❑At-Grd ❑Mound c~rcx. sizei X 411 RGravity ❑Dose ❑Pressurized 11;L.K Ft.2 [3;Sed rench ❑Dry Well ❑Holding Tank ❑Outfall pipe OESERVBD DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: ❑House 12 ❑JelI ❑Prop. line ❑Other_ ~c se tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover ❑Warning label ❑Pump/Floats ❑Alarm ❑Elec. wiring Absorption System Setbacks: ❑House Lit%7e11 ❑Prop. line ❑Other Ponding:_ ❑Discharge: oral comments: I INSPECTORS SKETCH OF SYSTEM LOCATION /1l~~~~',~~ ,+Li~%j,~"l~e-'2'rLy ✓~2~ ~ GVi t, L c.-Lr 1 ~ L ~k. I 'W Inspect 0~~ Title__ , r t i i AS BUILT SANITARY SYSTEM REPORT ;rR t,> <'c T0,7NSHIP _ ' "SEC. 7 T _N, R L~~W ADIJRESS ST. CROIX CO .ISCONSZN. . .DIVISION LOT LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW E'er 'RYTHING WTTHIN 100 FEET OF SYSTEM ~-t- ----L-- --I-;-- - 1 1 I j 1 i_ I ~--I - i ~ I, I i ( I S ' i f I 1 -1-- i r--~- - ! , 1 I ~ i I T . ~ - Indicate N a ,,cth. A, ,L c w TIC TAl':{(S)MFGR CO;ICRETE STEEL S cad e N0. of rings on cover / Depth DRY WELL ,FICHES NO. of width length area no. of lines :width length area-ydepth to top of pipe 33-ELATE ; RATE AREA REQUIF.E D AREA AS BUILT .i = r"V y Jr y e( 4 .1~ :claimer: The inspection of this system by St. Croix County does not irply complete .~oiiance with State Administrative Codes. There are other areas that it is not possible - inspect at this point of construction. St. Croix County assumes no liability for ;tent, operation. However, if failure is noted the County will mane every effort to '.~,2resne cause of failure. '.BASES AND OILS SHOULD NOT BE DISPOSED THROUGH ':'HIS SYS TL.i. 'INSPECTOR DATED / - PLU; (BER ON JOB -_L jA- LICENSE NUtff3ER°~~ REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM Sanitaty Pe-,,ml it -5,0 State Septic oZ NAME fown~ship St. Ctoix County Locat.ionlW -D-section SEPTIC TANK Size gattonz. Numbers o6 CompaAtmentts D.ibtance FAOm: We.tt 6t. 120 oA gteatet tstope 6t Bu i ('cfing_ 6t. W ~t.l'and/s __6t. Highwatet 6t. DISPOSAL SYSTEM Distance FAOm: WeU_ 6t. 12% oA gteateA 6 tope fit. Bu.i.E'd.ing 6t. Wettand/s Ft. Highwatetc 6t. JJ FIELD DIMENSIONS: 1 Width o6 ttench 6t. Depth o6 toch below t.ite ,in. I Length o6 each Zi:ne 6t. Depth o6 Aock oven tare .in. Numbn o6 tines Depth ob ti.E?e below grade in. lotat length o6 .k'_-ine/s 6t. Stope of ttench in pet 100 St. Distance between .2.ines {t. Depth to bedrock 4t. Totat abzotbtion aAea 6t2 Depth to gtoundwatet /6t. 2 Requited area 6t Type oU CoveA: Pape:t of Sttaw PIT DIMENSIONS: NumbeA o5 pitz GAavet around pitz yes no Outts.ide d.iametet 6t. Depth below .in.(?et 6t. 2 Total. abz otbtion area 6t z A AAea AequiAed 6t2 rn INSPECTED BY TITLE APPROVED DATE 197. REJECTED DATE 197 EH 115 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 Sqh f r a h! LOCATION: -_4_'/a, Section , T,1[N, R E (or) W, Township or Municipality f Lot No. , Block No. C? .-C v+^ c7 1A County 4r.'• Subdivisionl' ame Owner's Name: _14AItI~77%, Mailing Address: r t > TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW- ADDITION RP ACEMEN7 DATES OBSERVATIONS MADE: SOIL BORINGS PERCOL~Tf.ONTEST-6 - `SOIL MAP SHEET SOIL TYPE 6&141, i i PERCOLATION TESTS TEST DEPTH HOURS WATER IN TE$T TIME ` DROP, IN.WATE I_ EL, INCHES RATE NUM- CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTtRVAL BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINVTES PERIOD 1 PE 2 PERIOD 3 MIN/IN 0, Z Z' 7- P- /L ►r SOIL BORING TESTS C TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)- X) 3 S F 0F T's v - 34, 5; j s> AV 3C 7G C sv~~C s- b 2v 3 G s 36 s Y 5~ y is T5 r'!_AN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) ',,dicate on the plan the location and square feet f suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. Indicate scale ~ 4L or distances. Give horizontal and vertical reference oints. Indicate slope. r I v { i G j I, the undersigned, hereby certify that the soil test 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 beIi . Name (print) C Certification No. S-5,31- 3 x" cs C Address Name of installer if known 4C CST Signature LL COPY A -LOCAL ACTNOR; T Y PLB', 67 State and County State Permit # 24 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. OWNER OF PROPERTY Mailing Address: B. LOCATION: _1/4 - SAJ y,, Section Z21 T, 1L N, R El (or) ZL Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township c C. TYPE OF OCCUPANCY: *Commercial 7*Indust~rial *Other (specify) *Variance Single family- Duplex No. of Bedrooms No. of Persons--y- D. SEPTIC TANK CAPACITYTotal gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation 2C 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 1 :5 s ft. New_Replacement Alternate (Specify) Seepage Trench: No. of Lin al Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: _._Length r Width 11-1 Depth Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 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 Tester, NAME C. i4L L1I pv(J-o C.S.T. # S1 f 3 / and other information obtained from owner wilder). Plumber's Signature MPPRSW# Phone 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. y`1 s E VV m 1 . ~ f E w E E to _ Do Not Write in Space Below. rF COUNTY AND STATE DEPARTMENT USEQNLY Date of Application Fees Paid: State / L County Date Permit Issued/$ stect (date) Issuing Agent Na61e• 1 L ~1 3 i 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 -t.ate (pink copy) 4. Plumber (canary copy) Revised Date 7/1 /78 STAR PRAIRIE T.31 N7-R.18W. 55 JI /Nr~ t/NE I~ POLKI COUNTY ~ °1 y ~ y %e' a o ` y e L c7 man ~ C Hen y esa s 3 C 0 v v C -DOrra/d -DOUy/as f .p T;U b 65 b-C C s e 7 v 63 y .Larson 69 son t` a vx ~0 eM/h /Cat R✓and cis 41 b~Fs zo. d6 x ®v o~ dF~ zb 9 w~ o CEDAR L. g ib JC 5v v5a zoz z67./z o a. 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Snc`9 rc rsxrs f Can° L 7e72 a Dals 60 /6o I Kebha ai ata/ 3i ©/sda c.E o d /ycz~ 6/s 64 Q co/F Bs ~ fp SEE PAGE 53,Pe-"';rq SEE~PAGEr43 c5/Cro.~ f, -r„s NARD'S SKOGLUND OIL CO. BER N4RTHTOWN Phone: 246-4767 Schwan Plumbing & New Rich 17 Wisconsin Heating & HIGHWAYS 64 & 65 NORTH 540 Hardware NEW RICHMOND, WISCONSIN 54017 SOMERSET DEEPS ROCK Sales -Service & Repairs PHONE: 246-2236 Plumbing - Heating & Phone: 247-3764 Pump Work TWIN CITY ® Somerset, Wisconsin PHONE. 248-3760 CIIltssl.rai PHONE: 439-2905 J Bulk Form Delivery Star Prairie, Wisconsin s ' Gas - Fuel Oil - Diesel i AS BUILT SANITARY SYSTEM REPORT Rt1D DRESS S • c, , T0..TNSHIP -SEC. T *I, R FJ ST. CROIX CG' :;TY, WISCONS N. ' -,DIVISION LOT LOT SIZE PLAN VIEW Distances b dimensions to meet requirements of H62.20 SHOW E1rRYTHI„G WITHIN 100 FEET OF SYSTPi F11 -7' - I i i ~ ; ~ ~ I I i j 11 ~ I I J I I I I - I I- i 1---'- I I I I ~ I l i ~ II i I ~ I I I I i 1 ' i 1-4 - -r-+- _ I I I r- - - Y-+- _ I ,TIC TA,ti'K(S) MFGR,' Inds cafe Nonth A~'ntccwY / CO„ M1 , C2ETE ~ STEEL S cafe N0. oz rings on cover / Depth DRY WELL - CHES NO. of - width length area no. Of lines 1 width /j, ' length area depth to top of pipe IGATE1 RATE ) AREA REQUIRED_Y42_ ARE, AS BUILT_jL eiaimer: The inspection of this system by St. Croix County does not imply complete ._~iiance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix: County assumes no liability for ,te=, operation. However, if failure is noted the County will make every effort to .cr,.dne cause of failure. .ASES AND OILS SHOULD NOT BE DISPOSED THROUGH '-HIS SYSTEM. 'INSPECTOR DATED ILI ' PLU; BER; ON JOB LICENSE NUIMER CG Z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM SanitaAy Penm,i: t ` State Septic NAME Township ~ St. CAoix County Location ~14/ s Section SEPTIC TANK Size gattons. Number o6 Compantment~s Di,6tanee FAom: WeU )Z' 6t. 120 oa gAeateA LZope Buitd.i,ng _6t. Wl ttan&5 __6t. HighwateA 6t. DISPOSAL SYSTEM Di.6tanee FAom: Wett 6t. 120 m gneatvL stope 6t. Building 7 6t. W etZand/s Ft. HighwateA,----- 6t. FIELD DIMENSIONS: width o6 tAen ch_ _6t. Depth o6 ,Lock b eZow tiZe ' in. Length o6 each tine ~ 6t. Depth o6 Aock oveA tite in. NumbeA o6 Zi.ne/5 Depth o6 tite below gtade in. Tota.E Zength o6 tine/s t; 6t. Sto pe o6 tneneh in peA 100 6t. f Di,5 fiance between Zine/s 6,t. Depth to b edAo ck 6,t. Totat ab,5mbtion aAea 6t2 Depth to gAoundwateA - 6t. Requi4ed area 6t2 Type o6 CoveA: Papers qA Straw PIT DIMENSIONS: NumbeA o6 pit6 / GAaveZ aAound pity yes no Outside diameteA fit. Depth below inlet 6t. Totat ab6 oAbtion aAeg 6t2 z A .I 6t 2 AAea AequiAed l/; rn INSPECTED BY TITLE APPROVED DATE 197. REJECTED DATE 197 ryL '2 / ~/X J EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 p REPORT ON SOIL BORINGS AND PERCOLATION TESTS Stgr I ru hJ LOCATION: Section, T,4N, R L9 E (or) W, Township or Municipality Lot No. _ Block No. C 4 , vn 0- L- , County-Sr Q /I Subdivision ame Owner's Name: Mailing Address: TYPE OF OCCUPANCY: Residence _ No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION LA_CEMENT Z DATES OBSERVATIONS MADE: SOIL BORINGS ~ ~ -C- - PERCOLA SON ESTS.`~ t 179 SOIL MAP SHEET SOIL TYPE 'nIZ44 -{icel T. PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL SINCE HOLE HOLE WATER INFTER INTERVAL DROP,N.WATER/t EL, INCHES RATE NUM- INCHES THICKNESS IN INCHES BER 1ST WETTED SWELLING IN MIN - ES PERIOD 1 PEiRj9D 2 PERIOD 3 MIN/IN P- 4 n- P 30 L SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVE=ES TED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) - t- ~l-4 :2V'jGS jC StiS~ SSI GS a cs 54, C3 c 5 PLAN VIEW (Locate per co lation tests,soi I bore holes and suitable soil areas.) Indicate on ;Fug plan the location and square feet f suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. Indicate scale or distances. Give horizontal and vertical reference oints. Indicate slope. V' 00, t - }r fi- - I 4 - 4 - : I fi rt i-- t N fi 'I i IA ~ I ~ I i I I I ~ I I ~ i I 1 } 4 !17 Fti l i l i I, the undersigned, hereby certify that the soil test 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 bel' Name (print) L- Certification No. S-5-3,1 Address e-, "e-s- (Z Name of installer if known CST Signature a 4~cl PLB 67 I State and County State Permit # h 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: Section ~Z, TIN, R U (or) .ZL Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village 6J Township C. TYPE OF OCCUPANCY: 'Commercial 'Industrial `Other (specify) "Variance Single family - Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY_(j96 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete _2` Poured-in-Place Steel Fiberglass Other (specify) New Installation -X Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-PlaceOther (Specify) E. EFFLUENT DISPOSAL SYSTEM Percolation Rate Total Absorb Area~S sq. ft. New_Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: _Length. ~Width- Depth Tile depth (top) No. of Lines 7 Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 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 Tester, NAME C r4L- ulk1 (n>C.S.T. # 5' and other information obtained from owner uilder). Plumber's Signature MP PRSW# Phone #z y~ - ( " Plumber's Address i~ 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. r Al i Do Not Write in Space Below. R COUNTY AND STATE DEPARTMENT USE NLY Date of Application Coup - - 3 Fees Paid: State y Da Permit Issued (date) - Issuing Agent Na i _ Inspection Yes No State Valid# Date Recd 1. county (w ite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 -fate (pink copy) 4. Plumber (canary copy) Revised Date 711178