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~lS BUILT SANl']'Aia SY ;TEM RI'PORT
OWNER_ TOWNSHIP _ SEC._ _T _N, R W
ADDRES, ST. CROIX COUNTY WISCONSIN.
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of 1162.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
II dicate North:Arrow
SCALE--~_
SEPTIC TANK(S) MFGR. CONCRETE STEEL__
NO. of rings on cover Depth
UMPING CHAMBER SIZE PUMP' MFGR. MODEL NO.
GALLONS_Per Cycle_
RENCHES NO. of width - length area
ED NO. of lines width length area
depth to top of pipe
UMBER OF SEEPAGE PITS Outside diameter total pit area
~GREGATF _
RK RATE_ _ AREA REQUIRED , AREA AS BUILT
sclaimer_: The inspection of this system by St. Croix County does not imply
mplete compliance with State Administrative Codes. There are other areas t_,hX
is not possible to inspect at this point of construction. St. Croix County
sumes no liability for system operation. However, if failure is noted the
my will make every effort to determine cause of failure.
;ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM.
INSPECTOR_
ED PLUMBER ON
-f->=------ JOB,
R ,
LI C I NS ' -
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
San.Ltatcy Petcmit
State Septic
S+a r `p"Cri S Cjroi x County
NAME yer 1 S Towns hi P t.
LocationSE N~ Section /_Lot # ` Subdivision
SEPTIC TANK
Size gattons Number o6 compatcZment6
Distance 6nom: Wett Buitding 12 o tstope
Highwatetc_
PUMPING CHAMBER
Size gattonA Pump Manu6actune_n. Modet Numb
HOLDING TANK
Size gattons Numbers o6 CompaAtment,6
Pumpers Atan.m S yt6 tem
Di6 Lance 6tcom: W ett Buitding 12% s tope_ T_____.
Highwatetc
ABSORPTION SITE
Bed Ttcench
Distance 6 Lom: Wett Buitding 120 6tope
Highwatetc_
ABSORPTION SITE DIMENSIONS
Width o4 ttcench 6t Requiked atcea ~i
Length o6 each tine = 6t Depth o6 tco ck b etow Cite
Number o~ ti-nets Depth o6 tcock oven. Late _xn
Totat Length o j Una bt Depth o6 Cite below gn.ade
Di6tance between tinets 6t Stope ob trench in. pets 100 6t
Total absotcption atcea_ 6t Type o6 Covets: Paper. otc s ttcaw
PIT DIMENSIONS
V
Numbetc o6 pit.6 Gtcavet atcound p-%tts yets -_-__n'l
Outside diameter. 6t Depth below .inter
4 Tout absotcp,tion atcea_ 6t
i
Atcea n.equitced - _6t
107
INSPECTED BV TITLE
APPROVED DATE 19fr
REJECTED DATE 19 h--
REASON FOR REJECTION
State and County State Permit #
PLB67 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:
5 F '/4 "C '/4, Section , T_3,/ N, 'R j& E (or) W Lot# -City_
B. LOCATION: !5Z7-'
Subdivision Name, nearest road, lake or landmark Blk# - Village
Township ,
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family L-"' Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher AYES NO Food Waste Grinder YES 1--N-O # of Bathrooms)
Automatic Washer //YES NO Other (specify)
E. SEPTIC TANK CAPACITY 1,4-" Total gallons No. of tanks _tl,-~
*Holding tank capacity Total gallons No. of tanks
New Installation Addition- Replacement- Prefab Concrete L~
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolat' n Rate 1) - 2), $ 3) .5 Total Absorb Area--q96' sq. ft.
New Addition Replacement *Fill System
i /
/,~`file Depth 30 No. of Trenches
Seepage Trench: No. Lin. Feet /jOZ, r Width Sz DepthL
Seepage Bed: Length Width Depth Tile Depth No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size y Al
Percent slope of land d 9- % Distance from critical slope
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 i/ c l rje r ~~b ® )/t S C.S.T. # y and other information
obtained from (owner/builder).
Plumber's Signature Gc1 • MP/MPRSW# d Z Phone *-IV
Plumber's Addressor -L
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
5b -
1U
Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application V'a~ Fees Paid: State •.Qf~County 00 Date / _ l.~
Permit Issued/R 77 (date) '7 - =80 -Issuing Agent Name
Inspection Yes No 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 6/1 /76 ,
EH 4115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION:-5--C'/4, ~'/4, Section RL, -631N, RISE (or) W, Township or Municipality
Lot No. , Block No. County
Subdivision Name
Owner's Name: o 177.7
Mailing Address: i'/ s gr !e"~~ r'i e
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS C " 3c' - PERCOLATION TESTS
SOIL MAP SHEET SOI L TYPE 4'"15 O g! 'ter h •~~v a1~ j
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WA 1 ER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 4 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
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-
PLAN VIEW (Locate percolation 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. Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
OrL_
~ s
I
- - - -
,
E,E
lei
161 N 1 t
I I
I
I
, 3 t
1 # ~ s = I t
I, 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) C It Certificatior~_No- t < 3
Address L rn ie C 5
Name of installer if known % ~ - I
CST Signature
- es?~na staict4trT!'
COPY A
REPORT ON INSPECTION OF SANITARY PERMIT # 13,J_1 11166")
(1) Name and Address of Permit Holder Person/Persons at Site (2 )Date of Inspecto_n_
RQ414L'i Time of Inspection
ame, ress, icense NO. Of ns a ing Plumber
R)e IV
ha jfd IV
9
(3 )INSTALLATION CONSISTS OF: ® Septic Tank ❑ Seepage Trench ❑ Dosing Chamber
❑ Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BENCHMARK: (Permanent 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 ❑ NO; ft from residence;
ft from well; ft from property line. Type of warning device
Is the warning device installed? ❑ YES ❑ N0; 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: