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REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
• Sani tan y Pe ttn it
` State Septic,! .
NAME rownsh.ip S~. Cno.ix County
Location Section
SEPTIC TANK
I
Size gattond. Number o6 Compan.tmentas j
Vi.6tance Fnom: wett bt. 12% on greaten Atope 5t
Buitd.ing it. Wettand.d
DISPOSAL SYSTEM Highwaten it.
D.iatance Fnom: Wett St. 12% on greaten 4tope it.
Bu.itd.ing St. Wettanda Ft.
• H.ighwaten 6t.
FIELD DIMENSIONS:
Width o6' trench it. Depth of nock below t.ite .in.
Length ob each tine it. Depth o6 tcock oven t.ite .in.
Numb en of Lines Depth of t.ite betow grade .in.
Total .length o6 t iness it< Stope of trench in pen 100 it.
Diztance between .Z.ine,s it. Depth to bedrock it.
Total abz onbt.ion area 6t2 Depth to gnoundwaten it.
Requ.ined area it2 Type of Coven: Papex on Straw
PIT DIMENSIONS:
Numbers of pits Graved around pit.5 ye.a no
Out6 ide d.iameten it. Depth below .in.Zet it.
Total abzonbtion area it 2
A
2 3Z
Area %equkted it m
INSPECTED BY TITLE
APPROVED DATE 197 .
REJECTED DATE 197.
`lMk4ia6HJYYeuYadeawWir+.:.ara4++sw'ww'W,:..+w.w.t..w.r:'=-:
EH 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: 1~~'/4,~'/4, Section 2 T N,R~E (or) W, Township or Municipality '
Lot No. , Block No. County '!§77f` ('10U.,
Subdivision Name
Owner's/Buyers Name: Ir•~7'r'X_~toRM,aLL.I QP-oc,ex" ~~S•
Mailing Address: , ~f 3 C,(~ s s
TYPE OF OCCUPANCY: Residence X No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT 1,7< ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS 4--2-5--79 PERCOLATION TESTS - 2 SS- 7 2
SOIL MAP SHEET 67 NAME OF SOIL MAP UNIT 0',,YA M r f) C.
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
DEPTH CHARACTER OF SOIL RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MHWIN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- H Y rK . O` ry1 G d f
P_ if a, it CA 5* it 5, a it
P- 11 er N It , s/ It 0 l~ i • sr n J!°
P- %1 er t+ et r/ a' +r rr er
P- if re rl rl t/ H It
lr r/
P_ Ir w er v rr rr s+ rr rr
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
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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 square feet of absorption area needed for building type and occupancy Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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1, the undersigend, 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) e 'Ctl~ A, Certification No.
Address I~~- Wr I l'✓~t S
.Name of installer if known. = f
Copy A -Local Authority CST Signatu r-~l
' State and County State Permit #
PLB 6 7 w Permit Application County Permit #
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for Private Domestic Sewage Systems County 5,
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
4
B. LOCATION: % Section ,L~L, T,2U4 N, R (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family- Duplex No. of BedroomsY No. of Persons Vie?
D. SEPTIC TANK CAPACITY 14900 Total gallons No. of tanks C}n•'~'- ,vK wo
JOLDING TANK CAPACITY Total gallons No. of tanks 7>1,c •
refab concrete X Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement A
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate T Total Absorb Area s0~ sq. ft.
New Replacement ,K Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (toy) No. of Trenches
Seepage Bed: -K_Length Width Depth Tile depth (top)-xZ~~No. of Lines 7~0-
Seepage Pit: Inside di meter Liquid Depth No. of Seepage Pits
Percent slope of land- 9a Distance from critical slope
WATER SUPPLY: Private X 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 oil Tester, ~a
NAME =✓C~ p~ c C.S.T. # 5S ` and other information
obtained from Ct1•~ ' (owner/builder). r f
Plumber's Signature MP/MPRSW# - ~ / Phone #16,?`7--,ja 71
Plumber's Address -
01
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 DEPARTME IJAE 1NLY
Date of Application ` Fees Paid: State/Cou ,l ) Date
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Permit Issued! & .(date)` C` % 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