HomeMy WebLinkAbout038-1156-90-000
o
o o
00 p v>
a c~ m
0 0. 0
cn
0
N
~i
0
ti
0
ti
r
O N
a Z N
C O
LL
O +o E
Q d
3 M
v
Z N
Z EO
O
Z m m
N w a m
N I- Z
c C7
O Z :!t
N Z c
lA t- ~ ~
N
N ~
m O
Q ~
N
N
a
0 Z m Z
N C
d
N ffl
o - 0. U
o
O N_ ~ d 4
❑ ❑ CL
U) cn U) E
°
a
~a Z rn ao
a a a
is o
a E
0 ( O N
<n .j U U rn m }
N M `0
~ O O ~ i7
L fl%
m N fL
O pp 7
c C:)
O C) 3 N y c
O
Q)
® o rn ~ N
rp o ~
r \ y (0 ii ca
y p ao m
V) t `o
_ d o n U o
ICI M' M ~ N
6
Cn O C
•N' O m C\4
N = O Z C=
N
C.~ m
a L a T
E 2 fu 3
Q 0 a E 0 ro U
I
AS BUILT SANITARY SYSTEM REPORT
.R~~s,~ ~Ltruy~' , TO,TNSHIP,`if; 'SEC. TAN, R W
ADDRESS;i,~,~,,,~ ST. CRUIX CGU.7TY,~ WISCONSIN.
;DIVISIONd,~ LOT LOT SIZE
PLAN VIEW
"Distances & dimensions to meet requirements of H62.20
SHOE EVERYTHING WI'fHIIN 100 FEET OF SYSTLIf
I '
---r-- r- - ; -a- 1-
I
j f r I g`' 1 I j .-j
47
t - -r r- - -t--Y - i ---t
t r 1
I I I i I I l T
{ t--r----+- - t-- _ 1
}I
1 I I
Indicate NojL. Annow
;,TIC TAN?C(S)_ _CONCRETE_ STEEL S cat e
iWO. of rings on cover, Depth DRY WELL
;'NCHES N0. of width length area
x area
no. of lines width fJ2_ length 5,
depth to top of pipe
--,EGATE
RATE AREA REQUIRED AREA AS BUILT
;claimer: The inspection of this system by St.. Croix County does not imply complete
:.)liance 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
ten operation. However, if failure is noted the County will mane every effort to
,-crmdne cause.of failure.
'SIS AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST
`'INSPECTOR
47 Pd1,LT!,nF ER ON JOB
LICENSE NU:i3ER
RFP01;T OF IMSPECTIO_1--17MVIDUAL SI:T,JAGE UISPOSAI, SYSTEI-1
Sanitary Permit
Y i State spiptic
IE T61,111SHIp
t. Croix County
Si.T'TIC TA-'?P
.~~.ze allons. `lumber of Compartments
g
Distance From: Well "-ft. 12% or greater slope -'f I.
Buildings ft. Wetlands ft
Ilighwater ft.
DISPOSAL SYSTL:1 f~ Tile Field or Seepage Pit(s)
Distance From: tell 01L ft, 12% or greater slope ft
Building 1,JX__-Lft. Wetlands f
FIELD i;ighwater ~~-ft.
Total length of lines ft, Number of lines ~r. Length of
each line ft. Distance between lines ~ft. Width of the
trench ft. Total absorption area sq. ft
n eP t'l.
S.Z. of rock below tile in. nopt-h of rock over the in. Cover
Dver.rock,, Depth of tile below grade ~in. Sloe of
trench Z in ner 100 ft. Depth to Bedrock ft. Depth to
ground water --VM=p--t t.
PITS
Number of pits Ou ic'.e diameter ft. Depth below inlet
~ft. Grav, a-ou it: yes no. Total absorption area
-sq. f t
Square feet of se age trench bottom area required
• 4.
Uquare feet of eepage it ea r quired
Inspected by: Title:
Approved Date 19
Rejected , Date 19
EH 1 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 p
LOCATION: 0%, NX%, Section ~ , TXN, R [K t (or) W, Township or Municipality-- 57~~ 1^ (1F,!Q r
Lot No. -
Y- I Block No. County
S division Name
Owner's Name:
Mailing Address: N S C
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS 7
SOIL MAP SHEETf' ,/f SOIL TYPE PIAI'n 11A ~Ir- Lk lanly V'% ~mC
/ PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-A r 'lam Na 3 a
P-3 30
` % , 3 3 l
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)
B_ 3 9 9 8-.c .j S, do is ; S
7 LG d O 1 30 b S.
B- 9f- U- "Tis, 6 l5 01 L7
6? 2 q~ 4, - Z 1.5,51, o cs o
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of uitable 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. I dicate slope. 6v
~ I
h1kil"" Ty
i
t ~ I
€ t /
t
s t
-L0 L
d- ~
I i I 3 ~
I ti~ t
I I I ~ E y ' : Q I ~ h- '10 l s
t ~ ; I i t i t i i € I
i
-
t
t
-
Y .
! i R LI F-~ 1
it
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) 0,4L) 01 h ?'v W Certification No.
Address
Name of installer if known
t g,, CST Signature
PLIB-67 State and County State Permit #
Permit Application County Permit
r 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 p Mailing Address:
r %5 cl, s I\ K,)X~v r5 c'_
B. LOCATION: _-ALt-L'/i 11,1 Section T_~L N, R (?'i (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
p Stir r
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family _,A- Duplex No. of Bedrooms -3 No. of Persons_
D. SEPTIC TANK CAPACITY 600 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Y Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate S - - - -
A
Total Absorb rea C.----sq. ft.
New Replacement Alternate (Specify)
Seepage Trench No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length _ 5L Width--/2-Depth Y0 Tile depth (top) _2uNo. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land=s 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 Cert ied Soil Te e
NAME ,~,x~,e> C.S.T. # si - 53~ and other information
obtained from DU.1'0-• (owner/builder).
Plumber's Signature MP/MPRSW# /.56-3 Phone #-;?Yt - 73~
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.
b~`a
i
e
_ ~rt
4
C
Nq
4A
E
'Strut
Cjjbi
Do Not Write in Space Be ow FOR COUNTY AND STA~E DEPARTMENT ,SE ONLY
Date of Application y'- Fees Paid: State
t ` Conty T✓ t- C Date
Permit Issued{efed (date)
Issuing Agent Name
Inspection Yes_4_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