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PLEASANT VALLEY TWP.1j S/ c~%x o ~sy, B-
RUSH RIVER TWP.
2812 MALL DRIVE OFFICE 717 MAIN STREET AABY
EAU CLAIRE, WISCONSIN ST MENOMONIE, WISCONSIN
FEDERAL SAVINGS Business: 273-4945 ® True Value
AND LOAN ASSOCIATION Residence: 273-4155 REALTOR'
Hardware
"i - Car: 792-2732
- .i DAR-RAY Realty
319 EAST GRAND AVENUE Raymond Huppert Authorized PAINTS
EAU CLAIRE, WISCONSIN Dealers
207 NORTH BRIDGE STREET 372 WEST MAIN STREET 332 West Main Street 698-2377
CHIPPEWA FALLS, WISCONSIN ELLSWORTH, WISCONSIN Ellsworth, Wisconsin 54011
Woodville
Z! REPORT OF INSPECTION INDIVIDUAL SCWAGE SYST01 f 7
Sani tarry Pehrni t
State Septic al
l
NAME Lrownahip ki'UfP-S. - Croix County
~
L o c a.ti o x _N bj 5 Section
SEPTIC TANK
Size ga,t.ton4. Numbers o6 Compa4tmen.t4
D.ib,tance Fnom: We.tt 6.t. 121 wt gnea.ten 4.tope 6.t
1 "i4ding,__..,..,_.._._6.t. We.t.tandb 6.t.
DISPOSAL SYSTEM Nig hwaxen ,6$• k
Di4.tanee Fnom: Wei t 6.t. 121 on gnea.ten Aeo pe _6t.
Uitding 6.t. W e.t.tand4 Ft.
Ntghwa.ten 6t.
FIELD DIMENSIONS: _
Width o j' .trench 6.t. Depth o6 no ck b etow, .t.L.te in.
Length o6 each Une it. Depth o6 rock oven tite in.
Number- 06 Zi.ne4 Depth o6 -tiZe betow grade kn.-
To.tat teng.th o6 tine4 ' 6,t. S.tope o6 -trench in pen 100 6.t.
Di4$ance between Une4 d.t, Depth ato "b edno r-k 6.t.
Totat ab4 onb.tion area-, 6.t2 Depth to g4ouadwa.tea 6.t.
Requined area it2 Type o6 Coven: Papers on StLaw
PIT DIMENSIONS:
Numbers 06 pit4 G4ave4 around pit4 yea no
Ou4ide 4`Lame-tel_6.t. Pep-th be.tQw 4nee.t
To.tat ab4onb.tion anga 6.t2, a
Area negaiud it
2 nom,
INSPECTED 8V TITLE
APPROVED. O DATE l 9 7 . r`I.
REJECTED DATE
191
s
r C 1
E H 115 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 u- /4,15 l /4, Section T= N,R E (or W Townshi or Munici alit
Lot No. , Block No. i- County SST - C g l x
Rt ~ bdivision Name
A Oily
Owner's/Buyers Name: A
Mailing Address:
TYPE OF OCCUPANCY: Residence X No. of Bedrooms COMMERCIAL
,EFFLUENT DISPOSAL SYSTEM: NEW REP_L ACEMENT ALTERNATE SYSTEM OTHER,
DATES OBSERVATIONS MADE: SOIL BORINGS S / ' Z10 PERCOLATION TESTS 4~-
SOIL MAP SHEET NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES
RATE
NUM- SINCE HOLE HOLE AFTE INTERVAL
MIN/IN
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-
P- .710" 311 J_
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
p~~ J1 AA p
B-
f . J f' / ~~IYn - 6!U-
B- / ar s f l~
is
B- '0j
rr jpf ii
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan he location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 00 7 /4UNLIA,3 Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
LEA S
x ~
F t , `
A ioo I
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N
3
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PERX
,
13 F.
1, 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) IW'1) J Mg`LJ_' Certification No.
Address / l VA p P _ -
Name of installer if known 142c tki A 7? D / r
CST Signature
Copy A -Local Authority -'~'1>
PLB State and County State Permit # 67 ~j Permit Application County Permit{
' 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: AZIL" - '/4, Section T N, R E (or) Lot# City
Supbdivisiojn' Name, a - nearest road, lake or landmark Blk# Village
/ RM Lo Township ?J'~•N l~li~/= a
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family _ X Duplex No. of Bedrooms No. of Persons
SEPTIC TANK CAPACITY _10.10101 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 1s(
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM,: Percolation Rate Total Absorb Area sq. ft.
New Replacement X Alternate (Specify)
Seepage Trench: -A No. of Lineal Ft. 35 -Width Depth----1V-':-'Tile depth (top) rd No. of Trenches
Seepage Bed: Length Width Depth 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 Joint ❑ Community El 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 Soil Tester,
NAME A j% l lL TAD'r C.S.T. # and other information
obtained from (owner/bui Ider).
Plumber's S<Ail!~,At ,
C1Jff MP/MPRSW# _=ZA Phone
Plumber's Address Cs
q -V
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.
A 70 1 -
IA Y A-icy' &Xf) a w,
-JD
os*T L Y ~t n7 tc yTlf %s9~
pr ic, 4F))
4v,1C-D C=AS?.
A i607
EXIri~
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1)VS711Ll oN j X11 p[~c, tc p Ti`f
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12960-1; IV e- Ale T
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application (n /r/-~ Fees Paid: State County Dat )
L
Permit Issued/Rejected (date) 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
FAX
ST. CROIX COUNTY ZONING OFFICE
1101 Carmichael Road
Hudson, WI 54016
(715) 386.4680
DATE:
TO: Fax Number: 7
Name: nCJrdD~
FROM: Fax Number. 386-4686
Name:
Number of Pages Including Cover Sheet /
IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE
CONTACT:
NAME: wol ~Am~ltk
5 , Y/CO
TELEPHONE NUMBER: ' t3 ~tP ~O
i
S DO 51dq
21oc) L M d
531 A G
S I , TZAL) - (Z A) V.)
1 o Lv n
Wisconsin Department of Health and Sooial Servioes
Pl' 7 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. figNER_ OF PROPERTY
Name Address (Street, City, Zip Coda)
B. LOCATION OF PROPERTY_ WN'RE SYST21 WILL BE CONSTRUCTED, ALTERED OR EXTENDED COUNTY V f
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP?- ~ C
C. IS LOCAL PER21IT REQUIRED FOR THIS WORK? L ~ YES NO T f PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place • Steel Other
NUMBER OF TANKS TO BE LASTALLb:D: /w, yt a/
E. TYPE OF OCCUPANCY t
,Check One: One or Two Family Residence Coat,vcial Industrial Other i
~ (specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder _ YES NO Automatic Clothes Washer YES_ NO
Dishwasher YES '~t-- NO Automatic Potato Peeler YES a ' NO
Other (Specify)
G. MASTER PLUDER RAKING INSTALLATION
Name: Address= ~ (J {(%fl C~~~S License Number:
Signature of Applicant: MP RSW
Address: A)
I
H. (To be ompteted by Issuing Agent)
Date of Application C 7Gl Fee Paid
I
Permit Issued Nate) Permit Number;
Agent (Name) z Fort f1 / 1.
Tov.n, Village, City, County, etc.
(Specify) ;
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.00 for aa.ch septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks and coney orders should be made payable to
the Division of Health.
i Do not write in space below - FOR DEPARTIMINT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) r~ ^ (Date) See Co,-res.)
FEE RECEIVED VALID. No. PERMIT N0.
Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No
COMPLETE OTHER SIDE
` SEPTIC TANK PETIT NO. v` CI ,
t
• R E P O R T O N S O I L P E R C 0 L A T I 0 N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF EEALTH - PLU~Wll:G SECTI63
P.O.Box 305, Madison, Wis. 55701
Purnuant to H 62.20, Wis. Administrative Code
P$ R C 0 L A T I 0 N T E S T
Test Depth Mh,raoter of Soil }lours Water Test Time Drop 1n f?ater Level L.ol- `Unutes
Ihmbor Inches Thichnoss in Inohos Since Hole in Hole Interval Second ti Next to Last To Fa11
1st Wetted Overnight in Minutes Last Perlod Last Period Period Gras- Inch
Example
P - 0 36" Top Soil 1011, Cla 261, 25 Yes or No 30 1~2 1 2 12 60
RFCORD ATA FROM MINli Ut4 OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Cods.
S O I L B O R I N G S- Minimum 36" Below Pro used Absorption Syystc:n
Boring Total Depth Depth to Ground Wator Do th to Bedrock
Fumber Inches Cbserved Estimated Cbserved Estimatod Character of Soil with Thiokness in Ineh.s
Examlple
B - 0 72" X72" Black Top Soil 121J Cla 18111 Sand 18". Gravel 24"
-7 kzl,- 4,111t, fe
RECORD DATA FROM MINIMUM 01 3 BORE HOLE'S
YPE OF OCCUPANCY:
RESIDENCE: Number of Bedrooms OTHER: (Specify) Number of Persons
OD WASTE GRINDER, Yes No I DisImashers Yes No - Automatic Clothes Washer: Yes ~ No
FFLUENT DISPOSAL SYSTKI: NEW EXTENSION ADDITION REPLACz.,g
Tile Size 1 No.Lin.F~et Trench Width Depth,: 'tt Number of Lines --f
Seepage Bed: Length Width Depth Tile Size No. Ludes
Seepage Pits Inside Diameter - Liquid Depth ~ -
I, the undersigned, hereby certify that the po.roolation tests reported on this form were made by me or under my super-
vision in accord with the proeedr res and method speoified in Chapter H 6".20 (13), Wisconsin Administrative Coe , and
that the data recorded and location of test holes are correct to the best of Amy knowledge and belief.
NAME _ y~r I TITLE e) -
Type or Print
REGISTRATI011 10. or MASTER PLUMBER LIC-NSE NO.
ADDRESS { J / /
DATE 2`7 >-70 SIGNATURE U-1-1--e x~