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• AS BUILT SANITARY SYSTEM REPORT
,ER TOWNSHIP SEC. T N, R W
ADDRESS 77
ST. CROIX COUNTY, WISCONSIN.
'DIVISION LOT LOT SIZE
7-77777-
PLAN VIEW '
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
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• t
TIC TANK(S) MFGR. CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
,';CHES NO. of width length area
no. of lines width length area
depth to top of pipe
,ZEGATE
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
Lem operation. However, if failure is noted the County will make every effort to
:ermine cause of failure.
_:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTE~
"INSPECTOR
DATED PLU11BER ON JOB
LICENSE NUMBER
zREPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.i-ta.xy Pexrn.i,t
6
State Septic
NAME rownzh.ip 5.~. Cxo.ix County
L o c at.i o m Section
F.
SEPTIC TANK
w
Size f gattons. Number o6 Compax.tments
Distance Fxom: Wett 12% on gxeatex 4tope it
Bu.itd.ing'.f ~'f it. We.t.tands t.
DISPOSAL SYSTEM Highwazen - it.
.
0
Distance Fnom: 12% on gxea.tex ~6tope ~ it.
Bu.itd.ing it. wettands Ft.
H.ighwazeA -6t.
FIELD DIMENSIONS:
Width of txenchest. Depth o5 Aock below tite in.
Length o6 each tine17 ~-5 . it. Depth o6 rock oven .tile .in.
NumbeA os tine6 r Depth of .t.ite below gxade-- tin.
t i
To ad Deng th o 2 ine~5 it. S tope o tAeneh in peA 100 i t.
Distance between tina ~-t. Depth to bedxock - ~ .
Totat abboxbt.ion 6t2 Depth to gxoundwateA' it.
Requited area it2 Type o4 Coven: Paper on Stxaw
PIT DIMENSIONS:
Number o6 p.itz Gxavet axound p.it.5 yed no
Outside d.iameteA it. Depth beQow intet it.
2
Totat abzoAbt.ion area it z
A
Area %equtAed it2 m
INSPECTED BY- TITLE
APPROVED DATE 191
REJECTED DATE 191
5
E W"..5,
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
LOCATI Section v, TAN, R 4- 0(orW~, Township or Municipality W CM
Lot No. Block No. County ST' x n I IC
Subdivision Name
Owner's &:_1 c~lY
Mailing Address: /e,% Lo 0'4grm11r! 76 13' R 1 1JJl
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW i-- ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS ~4-q17? PERCOLATION TESTS ~7A
SOIL MAP SHEET SOIL T'YPE'
YPE JP&x
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_/ 3
l
P 3ORr- ID 4i / QrlL ~~G z C
P 3s~'~
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INC,H/ES OBSERVED ESTIMATED HIGHEST u (DEPTH TO BEDROCK IF OBSERVED)
_11- 11 _7 7-yl Set 4 1-4ft'o
B. 7 3
B S / Y ql I~l 3 e_
7y
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 number of s uare feet of absorption area
needed for building type and occupancy. T60too 13 AyAj!~gZw 94--1] V&9Pt2, Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope. 3 ~o A'/ -t,- 4 R T
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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) 64 Q.pE A7 Q"PyeL _ Certification No._S~-
Address /O -s' 'So /f!zmo y7- 7 LS&R 44:4 lc~►SG 'CV
Name of installer if known
CST Signature
State and County State Permit #
P LOS 6 7 Permit Application County Permi # ~ J
I
/
for Private Count
or rivate Domestic Sewage Systems Y *DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF j PROPERTY Mailing Address:
B. LOCATION: Sic Ar Section T2 N, R IF q (or) C Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township (,U1i11/~'iC'.~J✓
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family ✓ Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY , 1)-(' "Total gallons No. of tanks /
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete / Poured-in-Place Steel Fiberglass Other (specify)
New Installation A-- Replacement
Lift Pump Tank or Siphon Chamber Total gallons Pr fab oncrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rated • Total Absorb Area ^ s'4.`ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed:_ 6- _LengthAF 24 Width Depth Ile" Tile depth (top) No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 3 7y 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 .E C,r; ' L Lf C.S.T. # ~ - T11 and other information
obtained from (owner/4mTHcier).
Plumber's Signature MP/WRSW# 3S-e!Z Phone #
Plumber's Address - Sn-s S-• /'~F M2h~Y~ 3T lY.=~ E-.4,L,f Lc1r
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 B low I F R COUNTY AND STATE DEPAR, MEND USE ONLY
Date of Application Fees Paid: State County 41 Date -i
Permit Issued/AeMcl (date) Issuing Agent Name, y ` r
Inspection Yes No State Valid# Date Recd
county (whi e copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
to (pink copy) 4. Plumber (canary copy)
Revised Date 7/1/78