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AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP , EC. T~N, R Z
.0. ADDS SS
n. Kz ST. CROTyC Y, WISCON..IN4 =
.
'.'BDIVISION Y LOT LOT SIZE.
FLAN VIEW
l -Distances & dimensions to meet requirements of H62.20
SHOW F,VERYTEING WITHIN 100 FEET OF SYSTEM
.,L Iq
. $ -13
FTI(: TANK(S) L12> MFGR.~ CONCRETE ?"ST F E L
No. of rings on cover_ _ Depth_ DRY WELL
',EKC S NO. of width length are
:.D no. of line width length_ area
depth to tap of pipe
RI€ SATE AREA REQUIRED _MAREA AS BUI LT_.~-`-_
sciaimer: The inspection of this system by St, Croix County does: not imply complete
npliance with State Administrative Codes. There are other areas that it is not. possible
inspect at this point of construction. St. Croix County assumes no l.iabili.ty for
:item operation. However, if failure is noted the County will. crake every effort to
rermine cause of failure.
EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
DATED f / U PLUMBER ON JOB
LICENSE NUMBER - -C2 X-
(ti c C MANROL &
EX4 J
z
REPORT OF INSPECT10i,F INDIVIDUAL SEWAGE SYSTEM
San.itany Penm.it
State Sept.ic_
NAME i ownah.ip S~. Cno.ix County
Location Section
SEPTIC TANK
Size gattonb. Numb en o6 Compantmentb
it. 12% on greaten Atope 5
D.cd.tance Fnom: We22 it
Bu.itd.ing~it. Wettands ~ .
Highwaten it.
DISPOSAL SYSTEM
D.iztance Fnom: Wett sf j it. .12% on gneatet ztope 57; it.
Bu.i.Zd.ing_it. Wettand~s _ Ft.
• Highwaten1111►►\~\JJJJI J~~~VJJJJI-JJLL~~~it.
FIELD DIMENSIONS: Width o6' tn.en ch c~ it. Depth o j no ck b etow t.ite in.
Length os each tine ~ ) it. Depth o6 rock oven t.ite .in.
Number o6 tin e,6 13 Depth o6 t.ite below grade .in.
Totat .length o j .Z.i.ne6 Stope o6 trench in pen 100 it.
Di.6tance between .Z.inez '~2 it. Depth to bedrock ~ •
Totat ab.a onbt.ion anea ' __16t2 Depth to gtoundwateft,_ it.
Requited anea 70-~ it2 Type of Coven: Paper on Straw
PIT DIMENSIONS:
Numbed o6 pits Gxavet around pits yed no
Outside d.iamete/)' t. Depth below inlet _5t.
2
Totat abdonbt.ion atcea it A
Aaea requited it2 rn
f
INSPECTED BY TITLE
APPROVED , DATE-~ 19
REJECTED DATE 197.
~ V
EH 115 1
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF W2ALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: Section ( , 44fN, Rie~?,V(or) ,~1~~`ownship or Municipality
Lot No. , Block N -rZrl y /l 2 County `3t
Own Subdivision ame
Owner's Name:
Mailing Address: 4.1,-Z5
TYPE OF OCCUPANCY: Residence No. of Bedrooms = Other
EFFLUENT DISPOSAL SYSTEM: NEW K ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: -S•OILBORINGS -b r PERCOLATION TESTIS
SOIL MAP SHEET S01LTYPE ~i" ~
PERCOLATION TESTS
TEST IHOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- NCHES THICKNESS ICHARACTERN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P_Z
Ae~
3 !7 41
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- 9W /4AAC- 02 Y .;,4 S
B- 'y
?1lr 4y /_5
-Y vw
PLAN VIEW (Locate perco lat ion tests,soi I 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. S .01 00 6" <<' Indicate scale
or distances. Give horizontal and vertical reference ints. Ica slopes ft5 ,
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t I ) t I ~ 1, 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.,
Name (print) r - ~/Certification No.
Address &Z! c' A-i,.,.. ' 3es , 4
Name of installer if known
c
CST 1~-
`Y A - LOCAL AUTH0
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Y State and County State Permit #
PLB 6 7 r
~
0i- Permit Application County Perm
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:
jo 10f4 Z
B. LOCATION: Y4 ly /F ra,, on X , T~ N, R14 E (or) W Lot# City
Subdivision Name, st road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPAN Y: *Commercial *Industrial xOther (specify) *Variance
Single family Duplex No. of Bedrooms_ D No. of Persons
D. SEPTIC TANK CAPACITYTotal gallons No. of tanks
HOLDING TANK CAPAC1,TY Total gallons No. of tanks
Prefab concrete / Poured-in-Place Steel Fiberglass Other (specify)
New Installation 1I Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab c ncrete Poured-in-PlaceOther (Specify)
E. EFFLUENT QISPOSAL SYSTEM: Percolation Rate Total Absorb Area ° sq. ft.
New L/ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. J~ Width Depth Tile depth p~ No. of Tr ches
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 ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
!
I, the undersigned, do hereby certify that the infor tion I have reported is in acc rd with Sectn Hl~.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 p pared
by the ?7>fd Soil Tester
NAME C.S.T. # a and other information
obtained from (owner/builder).
> v
Plumber's Signature MP PRS 2 Phone
42- j/ 1 I 4 r1
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.
loo ~
5
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$ell iM
01
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application Fees Paid: State ;5-C. C Co my _ 6--[ Date 5--12 g~
Permit Issued/ (date) Issuing Agent Name_
Inspection Yes No State Valid# Date Recd _X_ -
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
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