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CROIX COUNTY WISCONSIN. W SUBDIVISION LOT LOT SIZE , Distances & dimensions to meet requiementswof H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - A i rr .,rL '"'7 e9 ' `tr R G 3 s iI di atte ox the Arrow rJ ' ( i I Ali, SEPTIC TANK(S) l MFGR. c: rms..=~t r. - CONCRETE x STEEL NO of rings on cover y Depth y PUMPING CHAMBER SIZE PUMP MFGR. MODEL NO. GALLONS Per Cycle TRENCHES NO. of wig- length area BED NO. of lines width , length 34- area ,~-y sY dept to top o pipe NUMBER OF SEEPAGE PITS Outsi e diameter total pit area AGGREGATE n .3;•~ r~ , 1,0 ( ,c PERK RATE AREA REQUIRED AREA AS BUILT K?e Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPECTOR DATED ✓ti 5 PLUMBER ON JOB LICENSE NUMBER ~I3EIIMI HSI130iZ gor xo uaama Galva uozoaasxi., - •RIIISIS SIHI 110nO 111 USOMa SS ION QgIlOHS S'IIO Qh^V S21SV31' •ainTTu3 3o asneo aura}a' 03 Iio33a XlaAa axem TTTM A3uno0 aq3 pa3ou sT aanTTE3 IT `zanaM.oH •uoT3ezado mals~ ao3 AITTTgeTT ou samnsse A3uno0 xTojD •3S •uoTjoni3suoo 3o 3u-[od sTg3 3e 3oad-SuT Ct aTgTssod Sou sT IT 3Eg3 ssaje awpo a.ze azagl • sapo:) anT3 sTu TmpV a3e3S g3Tn aousTTd", a3aTdmoo Al T Sou sao no0 0 •3S ~Cq ma inT o uoTaoadsuT aqI :aamTujoSy (Z* ZZ S Sd Vadv UT, alva 1K • 3I~932i9~ adTd 3o do3 oa gadap sale g3'suat g3pTM sauTT 3o -on r sale g32uaT g3PP11 X30 -ON. SaHOh--J( ZZHM AM g3dag aanoo uo s2uTi Io •OH uns s 100 •2IO.~i1 ts)x. s OIZ~ } 'IV "Os i LiOaav tp oN aaLaTpiui f~ ~ ~ I x t _ f r , iiaIsxs 30 I= 551 IIIHZIM OuIHIkuaAa MOHS OZ•Z9H 3o s3uamajTnbai 3aam o3 suoTsuacmTp g saousisTa. MS IA KY is 32IS 10Z IO'I ` NOISTAIQE., !1ISHOOSIM 'XINnO0 XIOUD *IS ` SsuccIy .0 M H `H Z •oaS ciIHSW-101 ` ~iSlic+t MOM WHISKS XXVIINVS VIM SV • REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM S a n -i. "t -z A y P (A ry) 4 t 4,7,/ _ State Sept4.c,,r,2 - 1ME Township -St. CAOtix County c .i.on~~~(~ -Sec on__~Lot # Subdivision PTIC TANK Size yv-_ gattona NurnbeA o6 eornpaA.tmen,ta stance. (Pi,om: IUeL 8u~.~dLn9--=--- 120 ~x.o~e Highwa>teA iMPING CHAMBER S ze" - gatt0na Pump Manu(jaetuA.eA M o d e t NumbeA I-U1Nu rAN& Size gaQ~ona N-umbeA o6 CompaAtme.nta PaMpeA---_- A.Q.aArn Sya,tem h Lance 4A.om: wezz Buitding-- 12 o 6,eope. Highwaxe.,c-_ -;SORPTION SITE tied TAeneh ta.nee {~A.orn: (VeU Bui.kdting t2o stope H.i.ghwa.teA ;SORPTION SITE DIMENSIONS Width oA tAe.neh RequiAe.d area fit Len_gtbr o6 e.ae_h, ti vte_ {fit Depth oA Aoeh beXtow .t~-.Ee in - Numb.eA o Qa.~.ea ~i Depth o6 n o e. fz oven t c k e i yr Totak Qeng h o~ Pine.a_ r 6t Depth oA tite beeow gAade D.ia.fance between finea 6t SEope o{ -tie.nch gin. PeA 100 6t To,to.X.At Type o6 CoveA: Pape.n oA s.tA.aw IT DIMENSIONS Number U6 P.i..ta GAave.f agound Pita yea no 0u ,3 de. d'came-te.n 6x Depth be.Qow -.nUt ~.t Tu t.a& boanp. 40vi ccAe,ci 6"t I AA e cc PSPLOTLD E3Y TITLE !PROVED DATE 198 JECTED DATE 1 t ASON FOR Rt _IECTION I Plb 67 State and County State Permit # Permit Application County Permit # _ f 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: Sits Y4 ./Yon '/4, Section T.06~N, R i E (or) W Lot#-City _ Subdivision Name, nearest road, lake or landmark Blk# Village Township !~!n rrlGiL ~J~~ C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms .3 No. of Persons 2, D. TYPE OF APPLIANCES: Dishwasher 9( YES NO Food Waste Grinder YES NO # of Bathrooms Automatic Washer X YES NO Other (specify) E. SEPTIC TANK CAPACITY /Oo v Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement _A Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) i Total Absorb Area1a sq. ft. New Addition Replacement A *Fill System Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches _ Seepage Bed: Length Jo ' Width :t i ' Depth y 3' Tile Depth 3y No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land V- e' 'tea Distance from critical slope 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 ~c (3';i-A . L r'3 a .t' a~T' C.S.T. # $ S`w c Zr 'i and other information obtained from :3"c i,, A A~` y (owner/builder). Plumber's Signature MP/MPRSW# Phone #'7/$= - 6'' - PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). /fJ"JSJ ~t Ti N~ L~~~S•r..~. ~ S~rrnr -r.erw ~ao~' fw.t ' S~Ffi`r! i f , ~ rc U' AthaMC.~O A ~ - b5hK~~ 7 aka„ 3 b"ehdr . 4~~ ' T r r'►✓ ~ !fe✓a'.c: A" 1 r t! A 30, d. _ x" IRON sra__._ y PJPA s a r Ar' Coe- F ' 1 i E r 3 1 7 [ 3 t e Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application Fees Paid: State County c-P/. Date ~6- 45 J7 Permit Issued/Rejected (date) ld -'/~.S _Issuing Agent Name et,Gc•-~E.'~' ~,(,1 Inspection Yes_,~ No Valid# Date Recd e •t 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 state (pink copy) 4. plumber (canary copy) Revised Date 3/1/75 REPORT ON INSPECTION OF SANITARY PERMIT # (1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection Name, Address, License No. o ns a ing Plumber Time of Inspection (3 )INSTALLATION CONSISTS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber ❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well: (7)DOSING TANK: Manufacturer: # of gallons: # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑ YES ❑ NO Wired? ❑YES ❑ NO 8 HOLDING TANK: Manufacturer o gallons construction ; depth to the cover ft; If septic tank is being used are baffles removed? ❑ YES ❑ NO; ft from residence; ft from well; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑ NO; Wired? ❑YES ❑ NO; Locking device on cover? ❑ YES ❑ N0; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑ YES ❑ NO (13) Has system been installed in floodway? ❑ YES ❑ NO Floodplain? ❑ YES ❑ NO DILHR-SBD-6095 N.05/80 Signature of Inspector: E H 11.5 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:3e Vjt) Section,T 1~N,R~E (or) ownship or Municipality Lot No. , Block No. A 7Z ~~PC County S7` ~~'O/X ubdivision Name Owa~ne_r's/Buyers Name: C Mailing Address: /)f ^V/ 12E601 TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLA EMENT-ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS 0 l e) PERCOLATION TESTS O SOIL MAP SHEET NAME OF SOIL MAP UNIT. PERCOLATION TESTS TEST DROP IN WATER LEVEL, INCHES HOURS WATER IN TESL TIM E RATE NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 Now 1 P- Sa9~f,~ rfSd/,P~- a ~ P- !rT ~l~~ c7/~ 0 a ,v o va y 1 2 / I P- ~2 s .~fc S 130'e c- 7e, P- SJ~ //z SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- Me~E ~l1":~/JN. L /s /s',v. S I "4nt.•~CCer Gf ;e&, . Z5- S'c B- z L eAJ ~1•,eV iv B- R. . S,.r,uf> 6 le . B- 3 71 WOVE 7z- 16 "6 la L / "4 ~N. S4,.2- J lxqp . 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 66- "4-0,p 3 Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. A~4AW 140 lee- E 10 a t < a re e , 0, N ;z 2 13 13 3 F Alf . : o ~ e ti ec4r- o r?~P-ecQ f7cx~~P -Te a~ I, 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) ~Aewr 7 Certification No. S Address ,eT-3 o XW Name of installer if known E DA✓ ~XLv9U~T/.v GDGtJ/At/ Copy A -Local Authority CST Signature ~ ~ - / 3 ~r m ,yam O • dI ~''/r7~1''rJ Y"~ 1 L~J~,~.' / %7"//'~i'rY" I'~/~J4.~. ~ Rrr v1'/1 ~ Z r~/ Jar / r ✓ L" 91. r'Jf/ ✓tol3s4iG1t Vim- /7.^~ !1 t°tZ iz ~i. '3~ r ti/ .+a ~TlYl+ a~ E r JAS /fa' ro'r" r- A Z) A 3 v / ] " /ROC rldtyte ~ Qw /fit tr A R J~c~.t 4' i y 11 DR sir. i i2 Plb. t-,a • WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Division of Health Section of Plumbing & Fire Protection Systems ON-SITE WASTE DISPOSAL INSPECTION REPORT Name of Premises Street City County Master Plumber Address Owner Address ❑ County Permits _ - ❑ Appropriate State Permits Type of Building: ❑ Public ❑ Single Family or Duplex CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM ❑ Building Sewer ❑ Conventional Soil Absorption System Septic Tank ❑ Conventional System-in-fill ❑ Holding Tank ❑ Alternate Mound System ❑ Seepage Bed ❑ Holding Tank ❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System BRIEF, FACTUAL COMMENTS AND SKETCH- E , , _L_ ice, J! 1 3 y mm 4k 4 , 3 i = " tF € f 4 ~ 7 ,F' o-i 1 P , F 4-1 E E E , - - P E E € r € l / ~ f F e t;~ P L as l.f t' s' b ¢ I € a I 7 ~ l , a € 3 r , 7 7 e 3 c ~ p 3 r ' f r E , , 3 t ~ E t . P w.. _ - 2 b..w.. w p.._ _ - .t t , . _ 3 E ~ a ~ ❑SEE ATTACHED DISCUSSED WITH PLUMBER ( ) Yes ( ) No SIGNATURE (Voluntary) DATE OF INSPECTION _ Signature of Inspector White - inspector Yellow - Local Inspector Pink Plumber or Responsible Party