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AS BUILT SANITARY SYSTEM REPORT
t
OWNER &.`%i , T'J'aTi1SrI1P ' SEC. T N, R W
P.O. APDREC ST. CRO CO~b Y, WISCONSIN
SUBDIVISION,, o r LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
SEPTIC TANK(S) MFGR. k, ",•r~.: CONCRETESTEEL
~
NO. of ri_n as; on cover Depth DRY WELL
TRENCHES NO. of width length area
BED no. of lines width length area
d t to tog of pipe.
AGGREGATE r-1, ~L-
PERK RATE AREA REQUIRED ;Ai<,EA AS BUILT
Disclaimer: The inspection of this system`by St. Croix County does"not imply complete
complia5ce with. State Administrative Codes. There are other areas that it is not possible
to inspect at this point of construction. St. Croix County assumes no liability for
system operation. However, if failure is noted the County wi make every effort to
determine cause of failure.
GREASES AND OIL: SHOULD NOT BE DISPOSED THROUGH THIS SYSTE
n
y
` INSPECTOR
*t
DATED o<V0 PLUMBER ON JOB It it-
LICENSE NUMBER
z
REPORT OF INSPECTI0N_INDIVIDUAL SEWAGE SYSTEM
' San.itvi y Permit
• State Sep.t-ic
NAME C ownah,ip St. Cro. County
i
Location Section
SEPTIC TANK
Size /0o gat.-one. Numb en a6 Compartments ~
D.cetanee From: Wet 120 on greater ztope3?) it
Bu.itd.ing_ it. Wettands
H.ighwater it.
DISPOSAL SYSTEM
D.idtance From: Wet 120 on greater 6tope_k-~Z) it.
Bu.itding it. Wettan&s Ft.
H ighwater it.
FIELD DIMENSIONS:
W iRh o4 trench it. Depth o6 rack below t.ite l,` in
Length o$ each .-.ine~~t. Depth o6 rock oven tite_Z, in.
Numbers a6 .-.ines Depth of tiZe betow grade-,L~in.
Totat tength of Zine6 it. Stope o6 trench- 7-' in pen 100 it.
Di.dtance between Una ~ it. Depth to bedrock tltj it.
34
r 4 ~Totat ab3orbtion area. &~t2 Depth to g-toundwater 6e /6t.
2
equired area ~ it Type oi Ccve~t: Paper or Straw
PIT3MbENSIONS:
Number o6 pigs Grave.- around p.it/s yes no
Outside diameteTae, Depth below in.-et 5t.
-
Tota.- ab~soAbtion it 2
~z
Area equ~red st2 rn
INSPECTED BV &a_ A.,d&t4.Y -W
APPROVED DATE 0 197
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
LOCATION: /4, Section r, _12 A, Rgq&(or ownshi or Municipality ~V y
County~~ U"c~i X
Lot No. B ck No. Subdivisio n Name
Owner's Name: Scan/
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW )C ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 7 a N PERCOLATION TESTS f0 -S= 7?
SOIL MAP SHEET SOIL TYPE S 7 D 1~•~l1A50,-b s/W--4 4/tA-',
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 to s~ ~ /v im , s
P_ Will.
TO 4"e- P41;0
P,_g 9Alx /V ( f Se rQ IC7 1-s
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST q (DEPTH TO BEDROCK IF OBSERVED)
/
B- l F6 5.4 71 •f `/Ov ~ •f-
~ k ~1GG Lem °j Q(~' s e f/~ r~ CD S `f (1h
B- 3 I6° m "SLR 63Co
y 6 A&,Ae~ > E~ /7 • S 7" Cod S G..
B_ 5 p6ti e- 7" t5, 13" 15-1's4 9/ C,,b
S 4o C'r S ~r C~tr
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate nu b r//•of square feett pf absorption area
needed for building type and occupancy. 6I-S-'f Indicate sca
or distances. Give horizontal and vertical reference poin . I t slope.
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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 belief..
Name (print) < < ~`D Certification No.
Address
Name of installer if known
CST Signature nature'
COPY A -LOCAL AUTHOR"
L
P-LB 6 7 State and County State Permit #
u Permit Application County Per
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: '/4 Section T_ N, R_ E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
E
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 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 Total Absorb Area sq. ft.
New 1 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
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private Q 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.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# 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.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State, County, . C ' Date
Permit Issue (date) 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