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REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Santitany Percmtt ~1
State Sept c
NAME T hip St. Cnoix County
Locattion Section Lot # Subdivision
-SE
SEPTIC TANK
Size !fit: gattons Numbeh oA eompa.Atments
Vi,stance {room: We t Buitdi.ng 120 slope
Highwate.n
PUMPING CHAMBER
Size gaZfonl Pump 'Manu,4aetunen Mode. Numbers.
HULKING TANK
Size ga lons Numbers o6 Compantmentls
.
Pumpers. - Atah.m S,Y,5 tem
Di6 tanee 6nom: Weft -Buitding 120 stope
Highway erc
ABSORPTION SITE
Bed Tneneh '
Di6tance._~)no_m:._: Welt
Hig-hwaten-
ABSORPTION SITE DIMENSIONS
Width ofi -tneneh ~t Requined anea 6t
Length o{ e-ach -fine {yt _Depth o6 Aock below ti. e. ~ 2_ in
Numb eh a in es
Depth o6 noCfz oven,tti.F_e. in
~t
t in.
7o^tak eength o~j f-i nes ~ t 6t Depth a tite be tow gar-ade E'
VDrch tanee between tines
~
J, t Shape. 06 ne.neh in. pen 100 6 Z D
a2"-ab,s 0A~jt,c-o►T -ane'.a Type 04 Coven: Pape.n on .t,eaw
PIT Dlp 1S IUNS
~,i,~ ti H i rf t6 Gnavet urca~und pith yes no
tau. s~.d _..dtiame e>t. 6t' Depth ,b,ef- oW-.,En-Zet
Tolkt_ab!~onp tiara anew {t
Ane.a ne.quined
r1
INSPECTED BBCTITLE
APPROVED DATE 198a
REJECTED DATE 198
REASON FOR REJECTION
I
AS BUILT SANITARY SYSTEM REPORT
a
OWNER ew" TOWNSHIP. ( `SEC. TkN, R &W
ADDRESS n a ,,••r ST. CROIX COUNTY WISCONSIN.
SUBDIVISION , LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 160 FEET OF SYSTEM
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11 _171-17 I I SCAL [_7 i
SEPTIC TANK(S)/000 MFGR. It) CC k . CONCRETE. A STEEL
NO. of rings on cover Depth
PUMPING CHAMBER SIZE PUMP MFG --AWL NO.
GALLONS Per Cycle
TRENCHES NO. of width length, area
BED NO. of lines width length -~~area
dept to top of pipe "
NUMBER OF SEEPAGE PITS Outside ameter total pit area
AGGREGATE
PERK RATE RE REQUIRED AREA AS BUILT ~5/_
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 PLUMBER ON JOB
LICENSE NUMBERHP 40
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REPORT ON INSPECTION OF SANITARY PERMIT # =9ZL
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspection
L ;It
Time of Inspection
ame, ress, lcense o. o ns a ing Plumber
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3 INSTALLATION CONSISTS OF: E ]Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanent reference Point) 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:
(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 ❑ N0; 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;
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 TREN H: 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:
PLB 6 7 ~ State and County State Permit #
Permit Application County Permit #
for Private Domestic Sewage Systems County Q
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. f OWNE~(R OF PROPERTY Mailing Address:
B. LOCATION: Section T~V N, R-+ (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
42 o k/ N T~ iCdALp 4~- T o w n s h i p ~ ~i2i
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY 100 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
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUEIZIT DISPOSAL SYSTEM: Percolation Rate Total Absorb Areal -sq. ft.
New-Replacement Replacement Alternate (Specify)
Seepage Trench: No. of i ; Ft. \1 idth .07' D~ee,pth Tile depth.. y(too~pp)-,, of Trenc
Seepage Bed: LengthWidth~_Depth~Tile depth (top)__n!=_7_-No. of Lines
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land- ~Ca Distance from critical slope
WATER SUPPLY: Private IX 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 ~~Ce**rtified Soil Tester,
NAME C5 R C.S.T. # and other information
obtained frog MPS ner/I~a+lder).~ ~ f r &-3 X60
Plumber's Si nature ~ 7U 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.
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Do Not Write in Space Belo FOR COUNTY AND STATE DEPARTMENT USE ONLY
Fees Paid: State 'n 't- I ' County D d l~
Date of Application -
AV,
Permit Issued/-R-e~d (date) - Z DC~ Issuing Agent Na y1f
Inspection Yes No State Valid# Date Recd
1. county (whi 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 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 5:3701
LOCATION'%F-5E%, Section ,TILN,R : (or) W, Township or 1VILr~~ z~~~
Lot No. , Block No. County ~TIe f
;'7 b ivision ame
caner' Buyers Name: ~`t
Mailing Address: t?'-0 6L'D I ►9' o-rid, r •i
TYPE OF OCCUPANCY: Residence L---' No. of Bedrooms -3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW, 4--' REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS e- 12- 86 PERCOLATION TESTS
SOIL MAP SHEET -NAME OF SOIL MAP UNIT PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP I : WATER LEVEL, INCHES RA
SINCE HOLE HOLE AFTER INTERVAL TE
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- 6c rr,- *A W6 -
P- G. ' / I / / / * " ii
P_ 11 "V e) 6W 511, T_
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P-
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SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
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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 Q -.Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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9, 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) Certification No. / P
Address I
Name of installer if known
Copy A -Local Authority CST Signatur
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