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AS BUILT SANITARY SYSTEM REPORT
~ C 1 ~f
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l , TD"~Rff Gb5urU SEC., T N, R Z W
O.,ADDRESS , ST. CROIX COUNTY, WISCONSIN.
iIDIVISION , LOT LOT SIZE.
PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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A r ~ I I I i i ~ ( I
I Indicate Notch ArroW i
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SCALE:
4 PTIC TANY.(S)MFGR. CONCRETE STEEL
NO. of rings on cover l Depth DRY WELL
;tLNCHES NO. of width length area
no. of lines width length area
depM t __~o top of pipe
'6REGATE
?IRK RATE AREA REQUIRED -6 AREA AS BUILT
lieclaimer: The inspection of this system by St. Croix County does not imply complete
;N.pliance with State Administrative Codes. There are other areas that it is not possible
,G inspect at this point of construction. St. Croix County assumes no liability for
j~tem operation. However, if failure is noted the County will make every effort to
:etermine cause of failure. 1'
tBASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
`INSPECTORi /
DATED _ PLUMBER ON JOB
LICENSE NUMBER
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REPORT OF INSPECTIJN INDIVIDUAL SEWAGE SYSTEM
San.i-tany Pe/unit
ic
/ C V State Septic
NAME N O S Croix Cou
Loca.t.iom Section
SEPTIC TANK
Size
2sD gattona. Numbers o6 Compattmen,ts-_ I
D"' tance F&om: Wet Gt/ 12% on gnea.ten e.iope ~7 6.t
Bui.tdi L6t. weeanda 6 t.
6~•
DISPOSAL SYSTEM Highwa.ten
Distance From: Wet ~at. 12% on gnea.ten ztopeb*;/ 6t.
Bu.i.bdi 06 6t. We.t.Eand.b Ft.
H.ighwateA 6.t.
FIELD DIMENSIONS:
Width o6* trench ~ 6.t. Depth o6 rock below. -tite-_-' -.in.
Length o6 each tine 6.t. Depth o6 tack oven .t.i.Ee .7-'" in.
37 Numbers 06 tines Depth o6 -t.ite be.Eow gnada.? o in.,
~C To.ta.L. Qeng-th o4 tines 6t. S.Eo pe o6 .trench Z in pen 100 6-t.
3~j1 D.i.a.tance between tines G 4t. Depth .to'bedaock 6t.
To.ta.i abzohbtion anea~6,t2 Depth to gnoundwa.te447 6.t.
Requ.in.ed anew t2 Type o6 Coven: Pape& n S.t&aw
PIT DIMENSIONS:
Numbers o6 p.itVoat Ghave•C around pits yes no
Outside d:iameDepth below .intet 6t.
Tota abso
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An Aeq unbt a 6t 2
n ed 6t
_2
INSPECTED TITLE
APPROVED -,DATE 196? .
REJECTED DATE 197 .
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EH U5 -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: SYN'/4, Sectiorr ,Tf--D_N,RLi2f W, Municipality C QTY OF /4 k-J
Lot No. , Block No. Subdivision Name CountyT GR7*~_ l,K
Ov $uyers Name: i= /14 \402!14L f\j AS "7- A-n 6-1
Mailing Address: Za `J s7~~/J v \
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACE ENT ALTERNATE SYS E`IV~ O`er r
DATES OBSERVATIONS MADE: SOIL BORINGS - RCOLATION TEST
SOIL MAP SHEET
NAME OF SOIL MAP UNIT
PERCOLATION TESTS °M
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-
P- DC_-> A'~ l v / L
P ~.Vp 7
P-
P LO~ . Z
P_
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
B- X30 A/ i 4- 7-5, /3"; f3N S A S 6-
B- (;r l
B- Co I:N. 6 B CGS - 5 4
B- 80 Cit1 r. 7 3 10 E i s. 1 as' s i... Z
B-
~e. 0
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. Indies e.
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I, the undersigend, hereby certify that a soil ests reported on this form were made by me ' accord with the procedures and methods
specified in the Wisconsin Administrative de, and teat the data recorded and location test holes are correct to the best of my
knowledge and belief.
i i•. Vin/ ; /~f~:. TLS, f ~/G.
Name (print) -3~ &A -F----, 1 ~ l) C . / ~ Certification No.
Address ! 4- ~ Cc) J L ~~•4-n , e)c_>C Som./ C> spAJ ~ Af L
Name of installer if known iM
Copy A -Local Authority CST Signature
.
State and County State Permit # Permit Application County Permit #
PLB 67 w
for Private Domestic Sewage Systems County ire
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PRO`PEJRTY Mailing Address:
S oK1~ 4Gr l s ~5' o
f- N V A~ 5 C 7 #0,0
B. LOCATION: ~Ct) _'/4, Section .2_5, T N, R_2Q E (or) W Lot# City O C'oitJ '
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms ~ -No. of Persons
D. SEPTIC TANK CAPACITY 1000 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete x Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement X
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate ZGL-Total Absorb Area sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Vyidth Depth Tile depth (top) No. of Trenches
Seepage Bed: ~_Length ~ _Width~_DepthTile depth (top) l,~`• No. of Lines 3
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- Z, e i/ C L Distance from critical slope
WATER SUPPLY: Private 'NZ Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
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 -5 A S /6 S C/-/ C.S.T. # and other information
obtained from 4 /Ujg (owner/builder).
Plumber's Signature MP/MP SW# / Phone #y394 - aS-0
Plumber's Address 0 G se
cy/S S L
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 O b Fees Paid: State / County , 0'0 Date v p
Permit Issued/Rejected ( ate) 20 10 Issuing Agent Name
State Valid# Date Recd
Inspection Yes No
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