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REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.itaAy PeAm.it -
State Septic
NAME fowndhip St. CAo.ix County
Locationllt' Section SEPTIC TANK
Size }J gaUon.s. Num,,ben a Compantments_ y
D.ib tanee FAom: W eZt 12% an gneateA sZope,-_'~ 6t
Bu.itd.ing,,4 4t. wetZands 6t.
11,ighwateA 5.t.
DISPOSAL SYSTEM
D.ietanee FAom: wetz St. 12% on gneateA 6Zope~_' 4t.
Bu.iZd.ing, - St. WettandIs Ft.
HighwateA -St.
FIELD DIMENSIONS:
Width oti thench .t. Depth a AacFz be2vw ti2e in.
Length o' each Zine_ St. Depth aS Aock oveA tile" in.
NumbeA v6 .i.ine/s Depth o6 tiZe below gnade~~-.in.
Total length ob Z.ine/s__ _5t. S.2.ope o6 tAeneh in pen 100 6t.
Di, stance between Una St. Depth to b edno c _6t.
Tatat abz onbt,ion aAea 6t2 Depth to gAoundwateA_ 4t.
2
Requ Type v4 Coven: PapeA oa St aw
.iAed aAea ~t
PIT DIMENSIONS:
NumbeA o,,4 pits GAavet. around pits yes no
Outzide diametvL St. Depth below ,inlet Ygt.
Total. ab~soAbt-iart aAea ~t
p.
2
AAea AequiAed {~t rn
INSPECTED BY F TITLE 1{ t~-
APPROVED E' ,DATE 197 `I.
REJECTED DATE 197
14
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a
6H 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 , T-'f` N, R E (or) W, Township or Municipality
/
Lot No. , Block No. County r
t_Subdivision Name
Owner's Name: ~"~''N
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS G PERCOLATION TESTS Al~r > k C-
SOIL MAP SHEET SOILTYP
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
d
C~(v1V ~4 I - 1
"Tlj
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)
T l ./t I ~r / J 5.
4P1 ~i.G\ ,.~j' f rr N/~ ;"/r
y
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet f suitable areas. I irate number of square feet of absorption area
needed for building type and occupancy. ""Indicate scale
or distances. Give horizontal and vertical reference poird~I curate 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 Ede lief. _
r 1 ~,c It
Name (print) - k Certification No
Address
Name of installer if known
j J
CST Signature
M1 n.-y n, M t+.,-F A e f "r' £ r A• r~ 1, y
Y
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PLB 67 State and County State Permit #
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: Section "j," Tl, RE (or) W Lot# City
AffUd"
Subdivision Name, nearest road, lake or landmark Blk# Village
Township '
C. TYPE OF OCCUPANCY.: *Commercial *Industrial `Other (specify) *Variance
Single family y~ Duplex No. of Bedrooms No. of Persons_
D. SEPTIC TANK CAPACITY ~i 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. Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Dp-pth Tile depth (top) No. of Trenches
Seepage Bed: A---Length. Width 4 r Depth 4V Tile depth (top) 4,
No. of Lines
Seepage Pit: Inside d' meter Liquid Depth No. of Seepage Pits
Percent slope of land--/c2 t' Distance from critical slope
G'VATER 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 Administr tive Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified it T
NAME C.S.T. #j( 4 and other information
obtained from (owner/builder). /
Plumber's Signa e 1 s~ ,V1 j
/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 Be ow FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application e Paid: State I r County D to `
Permit Issued/Rejected (date) t`~ r Issuing-Agent-Name r
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