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SEE PAGE 43
£S ,
AS BUILT SANITARY SYSTEM REPORT
OWNER ADDRESS TOWNSHII,y,;As0. , K t- SEC. T .,~N, R W
ST. CROIX COUNTY WISCONSIN.
SUBDIVISION tAj LOT LOT SIZE
S Gc/ Le PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• I
I
I di, ate ozthi Arrow
SCALD
SEPTIC TANK(S) MFGR. CONCRETE STEEL
N0. of rings on cover Depth
PUMPING CHAMBER SIZE PUMP MFGR. MODEL NO.
GALLONS Per Cycle _
TRENCHES NO. of wi tai - length area
BED NO. of lines width / length 7C ' area
depth to top o pipe c:
NUMBER OF SEEPAGE UTS outside diameter total pit area
et~ f ,r..1
AGGREGATE 1,6
PERK RATE AREA REQUIRED AREA AS BUILT r '/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
c ~c PLUMBER ON JOB
LICENSE NUMBER
REPORT 01 1NSVLCTION IND IVI OUAL SEDIAGE SVS TLM
Santt..zny I'c nrn.c ( p~ y~
St a ( e S e p,t'4. c--
IAMt '
l-owyAhip- _ St. Cno-i.x Cuun-ty
:+c(f tt.on cttiovt_1-Lot
1 1) f I C TANK
--_-_,_--_9a.teopus Nu.mben oc_ompantrnen.tA
t o yr 0 a rn : W (I f e 12% A e o p e.
1 _
th, ghwate't
WIVING CI(AMIiER
Si ze-- a.feoytA - Pump Manu6aetuh.en Model Nurnben.
1 UINo iAN&
S.4 ze ya. i'oyo Nurrlbeh o6 CompaAtmen.ts
Vurnpe~~ - A.ea-nm SyAte.rn
ti to n orn : W 41 13u-(.t d4 n,cl__ 12o 5 4ope__-___-_--_--
li i ]hwatVL
OI?P-T oN SI IE
tic-d T) t, c h ,,a
n taycc Ilorn: (Uee.k__ 13u..tediYlg __~/"PLu if 2 A~ope-----
H i.ghwateIL
;t)11 11UN SI'It- DIMENSIONS
LUtt -n e ych
d h o t R e q u -e. n e d a tc e a
6
Lry90h o6 each k-ine 6t Death. 06 n.ock befow tl(-'-ee
Nurnl)('11 n6 0+IcA De.ptIl o6 noch oven tli4e ty
I~+tal Yey_q-th o 6 e-irleA _6t Depth o6 ti e bc~.fow q.nade +ri
Din -tangyN b e -twee.y k -i_ne'6----------6t S'eope o{ tne.neh ---------~y. pe.n 100 (t4
l ot(t ubAOnpt.ton a~iea -_----6t Type 06 Coven: Vape.~t. af+- 1-t4aw
II VIMIN.tiIONS
Nurnbel: 06 Gtcavee. a.lcound pitA ye'6
yo
Oc de d.' arse to e 6t Depth bet'-ow 4.nket 6t
I o t a e a b L' oil p t t- o vt a. ~i e- er 6t
A I< e a i, c q u t it c d,a....-----' 6 t
N -III CI TITLI
- -
I'VROVI D DATE 19
1 .II CTCD DATE C 9 1s
IAtiON 101; 1lIJtCI10N
i
I
REPORT ON INSPECTION OF SANITARY PERMIT # 17 ql 'l
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
r q
42 t/ Time of Inspection
17a-me, ress, icense No. o ns a Ong lumber
,r
(3 )'INSTALLATION CON IS OF: ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
(4) BENCHMARK: (Permanent reference Poi-n-t7-7-scribe:
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 ❑ 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;
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:
EH 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 4C-. Y4,,IL'/4, Section_-A,/-,T:_OLN,Ri f(or) W, Township or10U"teh9ffWy
Lot No. , Block No. County Zj'
ub ivisl Name
w, ner's/Buyers Name: a?4
Mailing Address:
TYPE OF OCCUPANCY: Residence of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW 'REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS 09- -PC--
SOIL MAP SHEET w _--NAME OF SOIL MAP UNIT IVM 41- 1•'-
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- / '/,i? y Af_z r^ - t2a -Y 3/0-V
P- Z z I 3
P-
p -
P -
P_ T771
BORING TESTS
SOIL
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
~ e CC
I B-
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 .5 r, w,- Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
+r,07 VL'~ Isc. e~ ,,,-f . . t ~ e7tf~ w
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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.
t
v
Name (print)s ' - - Certification No.
Address
Name of installer if known
CST Signature A -Local Authority R _
r
PLB 67 State and County State Permit #
Vc/
. Permit Application County Permit #
for Private Domestic Sewage Systems County Z~/,
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERT Mailing Address:
y
B. LOCATION: ='/4 LL '/4, Section L , T --~kN, R-& e (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township,
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family plex No. of Bedrooms No. of Persons 2--
D. SEPTIC TANK CAPACITY l 'lx(`? Total gallons No. of tanks /
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel L! Fiberglass Other (specify)
New Installation 4-' Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E EFFLUENT DISPOSAL SYSTEM: Percolation Rate- ZL Total Absorb Area G-/- + sq. ft.
New y- Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length '7 C7 Width 12- Depth Z " Tile depth (top) I &I " No. of Lines z-
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land ,5-- E. Distance from critical slope
WATER SUPPLY: Private L oint ❑ 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 C tified Soil l Tester,
NAME t t~^I/ ,tom , F C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature Phone #~,7
MP/Mpl) W#
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.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application 11 A / fJ Fees Paid: State / V, 0-L1 County c I D / e,~
Permit Issued/Prejeeted- (date) _Zj/ Issuing Agent Nan
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53-
2. state (pink copy) 4. Plumber (canary copy)
Revised DatF
12. 1 o .
JD4~- Y4 81A~ -511
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