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N, R_~yW ST. CROIX C LINTY WISCONSIN. SUBDIVIS_ON LOT LOT SIZE PLAN VIEW /~3 y 70 Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM •.z u %JrC IG I I di a e oath Arrow S Ci4L - I I L-A SEPTIC TANK(S) / MFGR. CONCRETE STEEL N0. o. rings on cover Depth ' PUMPING CHAMBER SIZE PUMP MFGR. ~L NO. GALLONS Per Cycle TRENCHES NO. of width length L_area ; BED NO. of lines > width length- areal., depth to top o pipe NUMBER OF SEEPAGE PITS Outsi e diameter total pit area AGGREGATE PERK RATE _ RE REQUIRED AREA AS BUILT Disclaimer.: The inspection of this system by St. Croix C6,unty does not imply complete compliance with State Administrative Codes. There are other areas tha 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. CREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPECTOR DATED ~_>,l PLUMBER ON JOB LICENSE NUMBER Kt _PO 1~1 01 1NNQCTION - INDIVIDUAL SIL WAG L SVS TIt M Sam,i -tihy PC hm-it St a.te Sept.l.C. IAM1 l0wn4.p- 44tc zf- -St. Cao i x County uraxiuv~~ .S S~c;tcun S Lu-t SubdiviA i.on I PTIC LANK S-i zc ~gald'on4 Numbeh oA compahlmen.t6 4 5 tonce Alum: GIeXX fiui.l i(,i-ny 12 0 ~ f uC~e Hi c1l~wate~r 'IIMVINI; ('11AM61 R S -ize gaff 5 Pump ManuAactuleh Model Numbeh 1.UINu TANK "i 2I' da-l.lon6, Numbeh -uA 1, 111 r' It Atahm Sys to-m i Lance Alum Well 6u-4ld-in9- 12~ Mope- - It-ighwateh NQRPTI ON S171 Lied Toe nell Waw;v Alum: Wif BuMing_ r _-7 t 2 0 6~Cipe - Ui_yhwat e.h AKORVIION SITL DIMENSIONS Width oA trench t. Requ.-ihe_d anya At I qth oA each 1 ne At Depth uA &ock below the 4 n Numbvo "A lxweh- Vep-th 0A A0cc uve.lc Al.e Z ~n Iota(' Penc th u A At Depth oA tife. below grade r in Uintance between Yine6 At SXopV uA -then.ch ~.n. pvo 100 At total ah6uh_p_t-tun ahea At Type oA Coven: Paper oh 6-thaw 11 D I MI NS I ONS Namhvi o6 p-i t4 Grave -Y anound pi t6 ye6 nu Outs, <dv di ame ten. A.t Depth below tivtle A.t total abn~,hp ion uAva At Area AcgN(lVd At , I'1 ('II U ley rVK0V1 1) DA -I I ,7 - 19 n l if ('I[ O VA 11 198 , i A`,ON I OR 121 It CIION ,p i f I Via: C J LB State and County State Permit # P 67 u w Permit Application County Per t for Private Domestic Sewage Systems Count ' *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: Section 1,~_, T,22 N, R ~ (or) • W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township T 1) C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family _ Duplex No. of Bedrooms 5 No. of Persons D. SEPTIC TANK CAPACITY J1Q1) -i 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 A Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM:. Percolation Rate y~,¢Total Absorb Area sq. ft. New Replacement X Alternate (Specify) Seepage Trench: No. of Lineal Ft. Vlidth Depth Tile depth (top) No. of Trenches Seepage Bed:_, _Length /y7 Width 1-2 Depth 24, Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 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 Cer ified Soil T1ster, NAME C.S.T. # and other information obtained from - I (owner/builder). Plumber's Signature MP/ PRSW# 5~- Phone Plumber's Address 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. E E ~ f S. - t 4- . E m„,. n r.am. _..e ....A me,.., ..,e .x -.,.v,. .-.h.., -,a .:,eA«....-. j t s«.. e m n .ems ~ - 4 t1 f 3 E i Do Not Write in Space Below COUNTY AND STAT DEPARTMENT USE ONLY Date of Application FO COUNTY Paid: State / UD Co nt Date Permit Issued/Rejected (date) 4~7 Issuing Agent Name Inspection YesNo 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 EH 1,15 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:'/4, Y4, Section -5__,T3L N,RJ-:2 V (or) W, Township or Muxaci-pality Lot No. Block No. County ubdivlsion ame Owner's/Buyers Name: t ~~rZF'~/el _ 4 l eY/ Mailing Address: 4dn-;c34f,0 f4)! •5~& 7 TYPE OF OCCUPANCY: Residence _kNo. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENTX/ ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS Z©-JG - PERCOLATION TESTS SOIL MAP SHEET =;7 ._I5f1 NAME OF SOIL MAP UNIT ~CLIE1f _~,/r .Lo.~rr~ 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 MIN; IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P_ P- /l S n P- P- 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- 7 - B- 7 - c S y B- B- B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the.loSMn 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. C' q I d ~ gSfS + t Q3 7 a x(100' t r .Scc j.,a~~, I ~ i I N : I i 13 E S ell 47 I 3} 3 = 7 f S 3 ~ f may- s . ...m..._...~ . t_. 4... , n y....« ~ e g 3 s E i g 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) 7 Certification No. Address Name of installer if known Copy A -Local Authority CST Signature L . *J _ _ ~ r ~ / r- c' s~i~ ~~t f~ sn~%o w=~`- ~ - sc.~,~~; ~;(i~o He ..5.; ~ lQ % i _ ~x~✓ . J~C-~- _ _ -