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T, Ns R__W 0. ADDRESS ST. CROIX COUNTY, WISCONSIN. BDIVISION LOT LOT SIZE PLAN VIEW -Distances S dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i I i ~ ,+1 ( I I 1 ) I odi~cate North; Arrow 1-T I i SCALE . TIC TANK(S)MFGR. CONCRETE x STEEL NO. of rings on cover Depth DRY WELL -NCHES NO. of width length area no. of lines width j length, area depth to top of pipe, ?LEGATE 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 tem. operation. However, if failure is noted the County will make every effort to ermine cause of failure. SES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. '-INSPECTOR DATED PLU"11BER ON JOB LICENSE NUMBER F kc'~. - .x . F~ sic" jl M TUEPOU Or 111SPLCTI0:1--I,ZD1V1D AL SEJAGE DISPOSAL SYSTE11 Sanitary Permit r State Septic T&WNSHIP • t. Croix County SEPTIC TI!'?R Size ze gallons . `umber of Compartment , Distance Front: Tell ft. 12% or greater slope Building ft. Wetlands ft Highwater ft. DISPOSAL SYSTE:-1 Tile Field or Seepage Pit(s) Distance From: Neil ft. 12% or greater slope ft Building; ft. Wetlands f . FIELD 'Highwater ft. Total length of lines ft. Number, of lines Length of each line, ft. Distance between lines .V ft. Width of the trenchh 4'~_ft. Total absorption area ft. Depth of rock below t_ile in. Depth of rock over the in. Cover ovex:.roclc,, Depth of tile beloli grade } in- Slope of } trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS 'lumber of pits Outsic:e diameter ft. Depth below inlet ft Gravel a-rond pit: -___yes no. Total absorption area _s q . ft. .Square feet of seepage trench bottom area required Oquare feet of 'eepag.e nit area required Inspected Title J Japproved. Date 197. Rejected Date .197-. ~ 1 ,EH, 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH f - " P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: A44w"/a, A k, Section,4-' , T.~N, R /,e6d%(or)(6~township or Municipality Lot No. , Block No. County S Jet Subdivision Name Owner's Name: a Mailing Address: _ as/e',-,4 eat %S ye ;L TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW A -ADDITION REPLACEMENT f~ DATES OBSERVATIONS MADE: SOIL BORINGS 7 -.-;2 7O PERCOLATION TESTS/ 2 v SOIL MAP SHEET :2 FF yl SOIL TYPE I y 2 4 ` 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 L r _57e e roc ,2 P-2 dr P-3 "Ie" Cc ;2 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 lu to . 5 p6,. fc/kA,62' 1,1 ••~S W~JTQ Sf' S1 /s B- _7 d~v" /WsLrL '7~~'' /~(ii 6 •~S~.i (~r7' I~S/ 1~1K:R~$? S/.9~,ts B- S 1416 t- Y50 `.Sk, SIV `45, ~Ctik)ll SCS~ y PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the locationand square feet of suitable areas. In to num r of square feet of absorption area needed for building type and occupancy. OTC ' - - If dicate s le or distances. Give horizontal and vertical referencepoints nd.iczslope. t: i r e-- I--- ? .fie 0 A i E -100 , -s b 0 !A e'L tI I s I\ /^!I. J I I ~ ~ i I I f© I I i N "IN S f rt~ I 7Y 9- 3 YF2-- 3 AL Fi,4.,.`ly 4t A 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 lief Name (print) 31 4eel ` -r Certification No. Address /&6 r S ~'C Name of installer if known CST Signa e= ' COPY A LOCAL AUTHORITY ~ S t PL867- r State and County State Permit # 0 Permit Application County Permit # _ _71 2~ 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: NW % H GJ '/4, Section Lb , T_" N, R-/r- E (or) ( Lot# -City Subdivision Name, nearest road, lake or landmark Blk# Village Township LJ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family ✓ Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder ./YES- NO # of Bathrooms Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY /O O 0 Total gallons No. of tanks / *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) /0 2)_ 3) 6 Total Absorb Area sq. ft. NewJ~ Addition Replacement *Fill System 77;, Seepage Trench: No. L'n. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length5Width Depth7:411~ Tile Depth 56 No. of Lines li Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope ~~-Jr' 1, 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 P, C.S.T. # 5-19 and other information obtained from .Q ' o ne builder). Plumber's Signature MP/MPRSW# 41_11J5 Phone •-94Z3 Plumber's Address L PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). C~S hlo CIO _ _ ~ ° Ir ~'E Y N~ Y \e vv p Do Not Write in Spac B to - FOR DEPARTMENT 4 E ONLY Date of Application 1167-79 e Paid: State f/' Q County Data (e Permit Issued/Reject (d te) Issuing71Agent Name inspection Yes No 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 6 /1/- ` TRANSFER FORM PLB-67-T SANITARY PERMIT State Permit # . 0 Sanitary Permit # Count :3 f Sanitary Permit Transfer Date G (f Original Permit Issuance Date f ` i I F A. Property Location: I W '/4 Section T N, R E (or W,-' Lot # -City Subdivision Name, Nearest Road, Lake or Landmark BLK # Village TownshipL' B. TYPE of Occupancy:. Commercial Industrial Other (Specify) Single Family Duplex No. of Bedrooms Variance C. SEPTIC TANK CAPACITY 1AL 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/SIPHON CHAMBER Total gallons Prefab Concrete Poured-in-place -Other (Specify) D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate " ~ 'Total Absorb Area 1-sq. ft. New_ e Replacement Alternate (Specify) Seepage Trench:,., I Length Width Depth Tile Depth(top) No. Trenches Seepage Bed: -6 _ /,Width _Depth :F-~ Tile Depth(top) No. of Lines, Seepage Pit: Inside d arse er Liquid Depth No. Seepage Pits Percent slope of land Z Z Distance from critical slope AA r4 E. WATER SUPPLY: 'Private ❑Joint ❑Community ❑ Municipal Present Sanitary Permit Holder Phone No. Sanitary P mitt Transferre To: Phone No ! Name Name a )IL" Address A) Addres C~ / Zl ~Lt Zip I, the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with section H 62.20., Wisconsin Administrative Code and that I have sized the effluent disposal system according to the EH-115 prepared by the Certified Soil Tes r and/or any.. a additional soil tests that may have been required. Plumber's Signature MP/MPRSW # J---Phone #,i i Plumber's Address { ~ . 1 -71 L L C'z Information obtained from (owner or agent) PLAN VIEW: Provide sketch below of any revisions to original sanitary permit. Include direction of slope and all distances in accord with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property or neigh- bor's pro ert . If well has of been dnlle;~indicate L 7 of l ~ I I a ~ I E n{ 3 S ( uing Agent opY) 3. Owner (Pink copy,, DIVISION OF HEALTH 4. Plumber (Green 'conk) "'x 309, MADISON WI 5'