HomeMy WebLinkAbout020-1092-20-000
o o m f c e:,
Z 2~ No ~ o O N o
O W (n N J (D
Q 0 CD
(D d 0 O 1
(D W G O C O Nct
W N < a J
6 N
CD N O O Q
(D O 7 S O
O O N O e~
3 C)
C
N c r ~
d ~
o D a ~ °
W W
o ~
w W
z C7 r a
0 CO 0 CO
o a
(D
O O O !NI
-'0 N Z
I~ N N N ° D
C v v o
0
G (9 N co
D • d a N
O (D _ A O O
0 N W
7
~ (p O
Z W z
D CD o
V
Q N
O
(D 0
N C A
G O
C (D
O
(D
Q.
(D
CD cc ? Z N
a p Z
O
W
CZ
W < O N
CL Z
0 U)
3 U
3 z
(D 71
w
W 5 a (D o (A
0 0 fn ~0 (D 2
3 n-o -o cog
3 x (D Co F
D (D N
O O < ~ W C
W S 7
z CL
_ N G
N O O
y n W X 0 0 (D
d (0 o o O
(D w
D
O ID Q o V
W SN C,50 O
a a o v =
c cn o _
17 Q° r 3 2 W
< W O G O ID
0
o Q v 3 m 3
W 07 N-0.3
G 0 W o
W O < W
030 CL
07 0- 0 d q
W Co
CD
CO ID
> > W x
i 0 O
W 0
O ~a
Efl 0 ti
O
O (D r
O ,C w
00'0 00'0 00'0 lelol
sa6aeyO ;uenbu!laa sa6aeyO le!oadS s;uawssassd le!oads
;unowd fuoBa;eo apo0 Ie!oads aasn
:sleioadS
# 4o3ee :ale(] uo!;eo!;!}aaO 0 :;unoO w!elO :IIpaaO /(1a1101
0 0 000'0 puelpooM
0 0 0 000,0 Aljadoad leaauao
:LOOZ ao; sle;ol
0 0 000'0 puelpooM
0 0 0 000,0 A;aadoad leaauao
:8002 ao; sle;ol
uoseam a;e;s Ie;ol anoadwl pue-l saaoy sselo uol;d!aosaa
9002/£0/£0 :paBue40 Ise-1 :suoljenlen
0
:y;!an passassd :anlen;ailaew alej Me Jluvwwns $OOz
86£/9LL Z66 6/£Z/LO
OO t7£/ 6ZZ 6 L66 6/£Z/LO
aM 89£/6LLZ 06966L SOOZ/LO/b0
X3NNV 9£S/08LZ 8LL 66L 900Z/80/t70
ads .L abed/Ion # ood a;ed
:Aao;s!H Iaoaed
:sa;oN
MN MS M66-N6Z-Z£
(t'/6 096 t'/6 Ot, bud-unnl-oaS) :(s);oeal dbb'1 Nb'9 iV-ld id VAN 9£9108LZ 8LL66L
90/80/t70) NoscinH d0 AiIO a3X3NNV 9L£/£
:6p18 opu00/ 10018 WSO Z 10_1 MN MS id M662i N6Zl Z£ OIS
D~SVTVAViON-b'/N :Ield OZ9'6 :saaov :uo!;duosaaleBa-j
O11M OOL 6 dS
NOSanH 6 69Z OS
uo!;d!aosaa #;s!Q ad~(1
tiewiad . :(sa)ssaappd ~(padoad IeloadS = dS Ioogos = OS :s;O!a;s!Q
CIIRAUD~! 'M V1 Ni Nb'9 - O M b' Wi Nb'9 492JJJD i
iaumo-oo iuaiano = 0 'aaunnO;uaajno = O :(s)aauM0 :ssaappv xel
0 00 SOOZ/80/0
ad~(1;!waad #;!waad # uo!;eollddd eaad sales # deW Ole(] leouo;s!H Ole(] uo!;eaaO
NISNOOSIM 'AiNnoo X!02iO -1S ;uaaanO
NOSanH JO NMOl - 0,70 X ZH9L£'66'6Z Z£ # laoaed '31b'
L j0 L 3Jb'd
wd Meo Rooz/Kno 000-OZ-M U-OZO 103aed
K 7 'L tJ J 2 ~7 C) f'C ~7 A
REPOKf O1 INSPLCTION - INDIVIDUAL SEWAGE SYSTLM
Sart tan.y f E_nm,i t Q _
State. Senti.e 2
1MI -~,q owns h 'p St. Cno.ix County
catcun~(~ Se-ct~uv Lot ~ Subd4vision
III IC TANK
~4 zv ga~kons Numbers. c,~ ~umr~aAtmv.nta
ti tancv (nom: (Uv6Ulf' tdtng - --126
11i ghwateA
N1illNG CHAMBI K
Si_zv - 9afkon-~ Pump Manu6ac.tuh.eh. Mode.t Numboi
i.UINh i ANK
S4 zv - gaUon.5 Number u() CompaAtmeat6
Pumpv~~ - AkaAm Syatem
titance iikorn: WeU Eiu~~d~n9 - - ------12% hkupe.------- -
N,ighwa-te_fc
tiORPTION SITE
6 v d Trench
A tancv 6kom: (VeE~ 8utiEding_ 12 o h Lup v
HighwateA
, OKPTION SITE DIMENSIONS
W4 d t h o t4e.neh_~, - -fit KequAc i o d ahva {
E.ength o6 each tine{t Depth oA n.oc.h be.kow tT_.Pv ~n
Numbers o6 e4ne6-_----~ Nepttl uA Aoek ovv_n_ tiXv tv,
Tutae P.ength uA 6t Depth uA N-1v be.Pow gAa.dv {r,
D4 stanv be.twe.en T,ine_b _ t SeOPO 0() tAeneh 100
l ota,e ab,5on.ption Type uA CuveA: PapeA un s tAaw
'I DIMENSIONS
Numbvn uA C7.it,5 GAaveP aa.oun.d p4.t5 ye,5 kj0
O(At3 ( dv d~ amete)l 6t Ve-pth bekow tine t 6t
Tuta.P a ! oApttiun an_ea
Ariva llcqui cud ~t
i
VSI'l C71 0 KY TITLE
PKOVtD DATE 198
1E CTI D DATE 19 8
ASON f=OR Kf JECTION
- - - - - - - - - -
and County State Permit # cam` 72'
PLState ~B 6 7
Permit Application County Permit # ~
for Private Domestic Sewage Systems County IgL~ 4Z
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
t "S G
B. LOCATION: % Section 'LZ, T << N, R-Lj E (or) W_ Lot# 1 City
Subdivision Name, nearest road, lake or landmark Blk# Village
r
Township
C. TYPE OF OCCUPANCY: *Commercial_ *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY-[ 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 Q Total Absorb Area sq. ft.
New 2"\ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft._ Width _ Depth Tile depth (top) No. of Trenches
Seepage Bed:- Length S,
Width a Depth = Tile depth (top)-Z" ~No. of Lines
Seepage Pit: Inside diameter -Liquid Depth No. of Seepage Pits
Percent slope of land C. Lz. I C. ' 1e < E- < 'Lr lz~ Pal
j Distance from critical slope
WATER SUPPLY: Private n 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 Sgil Tester C
NAME b Z A } C / lS i /~((C f` ~-/y C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature <f'~ 'L ~l „yti r 'r MP/MPRSW# Phone Plumber's Address yak ~Z c 11< C1
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.
f
a ;
r 5
- a e e e . ~..a s . P
m~ n
a
I
- ,sam e _
k E ~
t
s
i '
~ i
g
I I j
Do Not Write in Space Below FOR COUNTY AND STATE DRTMENT USE ONLY
Date of Application Fees Paid: State County Date - d
Permit Issued/
Rttem d (date) /(n - ` b d
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
H 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/ 0'
LOCATION:5~'/4,A&_J /4, Section ~ ~ , INN, R~~~(or~Township or Municipality
Lot No. , Block No. 94t e S ~i Al County' S~ ~ y if X
/ Subdivision Name
Owner's Name: 7,0V `e 60-aa.¢_
Mailing Address:
TYPE OF OCCUPANCY: Residence X No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW X_ ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS /0-/
S= 7_7? PERCOLATION TESTS A)
SOI L MAP SHEET 1' SOIL TYPE C- r'
PERCOLATION TES
: _
1 EST DEFFH HOURS WA:
CHARACTER OF SOIL
VUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
+ER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
See 4re-
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)
I
X96., A®®~
6~/ V
jr ?16111
44a e_
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square eesuitab e areas. 4ndicate nio+ st ~r at ~srii
needed for building type and occupancy. ~f_ .~CSl7 ~ ,S.-dly Indicate scalp /
or distances. Give horizontal and vertical reference poin . Ind' AE!ee. i0e- _SX , -
i
i i I ~ ( 1
W p I I
(Ga a6 1
I
I N
PIZ
/1
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 mini,,strative Code, and that the data recorded and location of test holes are correct
to the best of m wledge a e ' AaAtits f S ®/~evSP,u
Name (print ! Certification No. SS ` /SY
Address B
Name of installer if known
CST Signature
~OPY A -LOCAL AUTHORITY
i
k ~
t
J
' V
-4
i
35
k ~
K c
bi I
d
1