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AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ,tTass,rEC.TN, R~W
ADDRESS ST. CROIX COUNTY WISCONSIN.
SUB
DIVISION LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62,20
SHOW EVERYTHING WITHIN 100 FEET OF SYST
S
~2 21up"" MWOMM
.r 00.11
di a e o th Arrow
SCAL
TSEPTCANK(S)I fMT'GR. CONCRETE STEEL
W7 7-o rings on cover Depth
I'UMPING CHAMBER SIZE: PUMP MFG R. MOIL NO.
GALLO -S- Per Cycle
TRI.NCHES, NO. of width length ~ area
ICED NO. of lines width length area
depth- to top of pipe 9 4
NUMBER OF SEEPAGE PITS Outside ameter total pit area
AGGREGATE
PERK RAn. RE REQUIRED AREA AS BUILT 4E22
Disclaimer: The inspection of this system by St. Croix County does not imply
complete compliance with State Admi_nistr-ative 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.
GREASE'S AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM.
INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER 90LTe,;~Z- AZ
RI. PORT Of INSPECTION INDIVIDUAL St:UTAGE SVSTL.M
S u rt,. t, m y f' c n rn-i .t _cas-e
State Sept,,i_c__"_24
AM1 Towvt~htir~ - - St, cnuc" x Couvt,ty
ti-uvl ---:Se.VIon-34LI Lot Subd,i_v.i,S i-on
I I'11C "TANK
C aYY.onb Nuin bc~'t uc t,III pit it tIn evtt6
1rittcc (~ttrIII : We.ee We
8u41 V11 ,i-viq IZ° 5e0 1rv -
Ht:dltwa to-n
WIPING CNAM81I)
S<ze gaY_f'uvt'S Purr nt ''tt.ttcen Modek Numb(!n-
1)INo IAN
I~
't ze -_yaI fovtA Nei rib e> > Compan-trnevt-t,~
I' it in p e it k a -m y6 t e_ rrt
futwe 0 it u III : I, oTe it t,dA_vt.G 12 a bkup e
If t cl It w a .t e h
ORPTJoN 1T1.
I'i e l I / \ ~L e- YI. C Lt
t o VI C P { h U to : lU e X--- 13 u ti I d,(' _ n q- 12 `0! k. o I c
114 _ ybtwat e_/I
O11) 1111ON SITE "DIMENSIONS
U1-t d t 11 u h t A e_ vi e Gr t R e it t n o d a n e_ a
I_evigtht a eaeh 6vte_ Def tit- an.ueh bel ow ,tAi.Xe !Z vi
Nurnbe~t u( T.iyte6 Del,th 0 Luc-h u vVA -t.t-!'e - rri
Iut- aE' Y evtgtit o~ k,x -vte.a - - 6t Dep.th oA t e. be-T'uw grade ~vt
U-j etit it e() bc>tweevt ktivte_b {~.t Seope u{ tne_ncitivi. p e.~t 100 r5t
1 u tai abh un.ptt on it !ce h~ I yp e u h Cuve4 PitpV,n_ aA 5 tIcaw )
I
II 111 MINSIONS
Vutill) eIt u~ Itt 1 Grave e o.,,tound p th ye! it
Uu f:, r tlt(Ii anio test {-t: Deptlt be-Pow t.vt~ e-t fit
taY lt~lu~t1_t tioIt a~tea -t
Alt Na 1rrtltt( ~tPd t
N I'I C IITLL
1'ITOVI D DATE 19 8
I 1ICT1 D DATE 198
' I ASON I Ok' R I R CTION
C~~~Q
State and County State Permit # 99,-1&
PLB67 Permit Application County Permi #
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. CATION: 11l '/4 r Y4, Section T N, R E (or) W Lot# ity
Subdivision Name, nearest road, lake or landmark Blk# Village
Township i,~ t~
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family A-'-- Duplex No. of Bedrooms 3 No. of Persons-_
D. TYPE OF APPLIANCES: Dishwasher k--'YES NO Food Waste Grinder "`-~ES NO # of Bathrooms
Automatic Washer 4--TIE'S NO Other (specify)
E SEPTIC TANK CAPACITY 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. EFFLUE DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area _sq. ft.
Ne dd' 'on Replacement *Fill System
Seepage Trench: No. Lin . FeetQ Width Depths Tide Depth No. of Trenches_
Se ength -Width Depth Tile Depth No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size _
Percent slope of land 6o °1a 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 Certifi Soil Tester,
NAME C.S.T. # and other information !5P -
obtained from (owner/builder).
Plumber's Signature /MPRSW# Phone"
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application 9v Fees Paid: State IV, (!tt) County Date life)
Permit Issued/Repeated ( ate) . Issuing Agent 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)
Rei,;vec Date Rl1 /'6
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON jjS~~OI L BORINGS AND PERCOLATION TESTIS
LOCATION: A Section 3 T~N, R /?E (or) Township or Municipality ~'1 r~ % G+ {i
County e
Lot No. , Block No. t !r n
Subdivision Name
Owner's Name: 1~ IA C -e I, " , h
Mailing Address: U e lir Lo `i
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW >C`--ADDITION ADDITIION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS r PERCOLATION TESTS 4
SOIL MAP SHEET! SOI L TYPE
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- s
S7
P-,~ 48
P-5 36 1 L
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_ 1 f 6 i fs s
B_ :3 S9 ~4 G s i -7-$ 79 s-
s
7 7S (j 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 f sgyere feet of absorption area
S needed for building type and occupancy. Sa +y e.. ch ~4 S ~ Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
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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 belief.
Q
Name (print) Cr 6-'f e-_ z 4"4- Certification No.
Address
rlame of installer if known ,may,
CST Signature A
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REPORT ON INSPECTION OF SANITARY PERMIT # 2'
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
1 7 " j
7_"I1 - yZ,4 - Time of Inspection
ame ress, icense NO. o ins a ing Plumber
_2 7_3
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 ❑ N0; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ N0; Wired? ❑ YES ❑ N0;
Locking device on cover? ❑ YES ❑ NO; 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;
the 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.05/8~
Signature of Inspector:_