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AS BULL;:' SANITARY SYSTEM REPORT
OWNER TOWNSHIP :4j- SF,C.,` t7 T LN, RL-LW
ADDRESS- ST. CROI4xc UNTY WISCONSIN.
S U Ii D I
LOT LOT SI7_E
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PLAN VIEW ~f 3 g -7
Distances & dimensions to meet requirements of h62,20 ~q3- _
SNOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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di,ate orth Arrow -
SCALE:
SEPTIC TANK(S) FGR. ,e ea o./~ / CONCRETE _4__. STE1 L
IN 0. o rings s on cover. ~ Depth
cf s
PUMPING CHAMBER SIZE rS"'~ PUMP Mr`GR Mb L N0. &2f>
GALLON`tii } er Cy Ie -
TRENCHES NO. of width length area
BEID NO. of tines width f Q, lengthy ~ area depth t.o t:op o pi.pe f
L
NUMBER O SEEPAGE PITS 0ziw e "i.aM Ler total pit area
PF,RK RA'1'P;z /r. RE RED &I 5--
Disclaimer: AS BUILT, C7
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 i_s not. possible to inspect at this point of constructi.on_ St. Croix County
"Issumes no liability for system operation. However, if faflur.e is noted the
County will make every effoitt to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM.
l 7
INSPECTOR
DATED l a PLUMBER ON JOB
LICENSE NUMBEEFs
6
' REPORT OF INSPECTION - INDIVIDUAL SLWAGE SVSTLM
San4 .tan y Pehm.c- t_--c-9-7-S
State sep-tkc.
;AME Townehip St. C&oA x County
c a do n S Lcj sik4jj_S e c:.t.i o n3(jL o .t N S u b d.i v.ie 4. On
IPTIC TANK
S,ze /S gatIon.6 Number o6 compantmente
6.tanee 64um:. etZ Building -12% 6tope
Highwate4
LIMPING CHAMBER
Size-~ yattOn4 _ Pump Manu,6ae.tu4e4-,~ Mudet Numbers
OLDING TANK/
4 'j Size. gaxj~na. Af mbe 06 Campantment~
Pumpers AX Kfn Sye.tem
lietanee 64om: 40 Well i Building 12% oYupe__
Highwa-ten
8SORPTPON SITE
Bed T4e.neh
(,stance 6Kom: Well 8u.i.Edin 9 t2% exape
H.ighwaten
/;SORPTION SITE DIMENSIONS
width o6 tneneh 6t Requ,(red an,ea_
Length u6 each line 6t Depth oA Koch be ow .t~xe___t~- 4 rt
Number u6 tinee 3 Depth u6 tuck overt tide -(.n
Totak Y.eng.th u6 ti nee92 6-t Depth oA tite beruw ynude--- --i,n
D.ietance between t.i.nee 6-t Slope u6 trench kn. Pell 100 6-t z
104Nt abovh tt'vrt a/.eu
N 6.t Type o6 Cu ven: Papers un QQ~tn~aw
/I DIMENSIONS
Numbvh u6 pitbG4avet around p-"t,6 yee _rtu
Ou.t,64dg d.iame,ten 6t Depth below .inte-t 6x
total aboonp.t.ion 4 ea 6t
.Area nequ.ixed
NSPECTED, 6r-1-,,, TITLE
1jPROVED DATE - / 19
JECTED DATE 198
MASON FOR REJECTION
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PLB 67 State and County State Permit #
A, 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:
el 74-2:
B. LOCATION: Section, T N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village oe=
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family ✓ Duplex No. of Bedrooms ;p No. of Persons
D. SEPTIC TANK CAPACITY !y' otal gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
l
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 Alternate (Specify)
Seepage Trench: No._of Liipeal Ft. Width Depth Tile depth (top) 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_ 4 %i 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 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 CertifSoil Tester,
NAME C.S.T. # other information
/1 - •
obtained frgm (owner/builder). ,
Plumber's Signature W/MPRSW# Phone
Plumber's Address f, Z
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 A~~ of 6) Fees Paid: State y-~; County Date
Permit Issued/Reteeted (date) /~'/U-STS Issuing Agent Name
Inspection Yes r No 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 i 15 Rev. 9/78
REPORT ON SOIL BORINGS AND-PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISO! w WISCONSIN 53701
LOCATION ` ' %!L ea, Section ~!j,T~LN,RLZE (or W ownshi r Municipality
Lot No. , Block No, County----:', 7- <Z•.niL_-,.-_j
Subdivision Name
Owner's/Buyers Name: /rit .t~s .
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms / COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ✓ ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS %2-'2 C3c PERCOLATION TESTS
SOIL MAP SHEET C) NAME OF SOIL MAP UNIT
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- i < -a
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-
B- L
B- tom/ F
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 Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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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 Certification Address of installer if known ood_~-
Copy A -Local Authority CST-Signature n. -
REPORT ON INSPECTION OF SANITARY PERMIT # 2% y
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
me, Address, License NO. o ns a ing Plumber Time of Inspection
(3 )INSTALLATION CONSISTS OF:' ❑ Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanen re erence oint 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:
M 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 ❑ NO;
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;
li.neal 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.05/80
Signature of Inspector:
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