HomeMy WebLinkAbout181-1001-95-000
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UPOFT OF INSPECTION--IATr;NTTI,TJAI. SEWkGE -DISPOSAL SYSTEM
P';I w', Y TRF:.A`rPTMNT consists of Septic Tank: Other (Describe)
SF.-TIC TANK: Distance f_rorz: Well ft., Lot line ft.,
]i1Ji ding ft. , Iiighwater Mark -ft. , 127, or greater slope
ft. , ff-e and ft., Cistern ft., No. compartments
Liquid capacity gal.
ETFLti'., ;`A' D ~>FJr 1L SYSTEM consists of Tile field Soepw e
Fig Seepage it or Tile Field: Distance from: TJell;96Lft.
Building ft.
Lot Line -f t . Cistern ft. Ilighwater Mark of water course
ft. S"tope 12% or greater eft. Wetland ft:
Total length of tile lines ft. F`dumber of lines: Length
of each lin ~&-6 ft. Distance between lines _4--ft4idth of
trench < 1.1 inc. Total effective absorption area of trench
bottom sq, ft.
Depth of filter material below the 16 in. Depth of fi e
material over tile in. Cover over filter material
Depth of tile below finisha ~ e
d grade in. ..lope of trenc
bottom min. per 100 ft. Depth o.f_[3i d-rock ft. Depth
to ground water - ft.
Ni-IiI,er of Pits . Outside diameter ft. Depth below inlet
ft. Lining material Gravel around pit:
yes. No. Total absorption area sq. ft.
Square feet of seepage trench bottom area required
Square feet of seepage pit area required
Inspected
by:
Title. /
/ o
Approved Date w t 197").
Rejec d Date 197v
I
,c County, To-, m- oi-
Uwn a r. ) CX-4 A
-
Sanitary Permit No. Property Address
Septic Tank Permit No. L 7 Subdivision
Plb '67 State and County State Permit #
Permit Application County Permit # _4~
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:
Z4 Id c- X-1 C Vkl'
B. CATION: '/4 '/4, Secti n T ~ N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Z ic e_/-Village
SCSI >ei 5 e' .t
W-5;' `j z 1 W -,Yt-Township
1W 4 C',
C. TYPE OF OC UPANCY: *Co ercial / *Industri *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms--
Automatic Washer 1-1YES NO Other (specify) 2 /,(n 5 h e-;s
E. SEPTIC TANK CAPACITY/ Total gallons No. of tanks -
,
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ,_3 2) 41 3) , f Total Absorb Area S' ya Z) sq. ft.
New_t,,~Addition Replacement *Fill System
Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length IDO' Width Depth 3 Tile Depth No. of Lines 1 L~
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Distance from critical slope Z/
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 / / Ghgr I/ JA /V62a/f 1 h C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# /0 S - Phone #,2 y~ - 5 ~ -2-
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Spa a Below FOR DEPARTMENT USE ONLY
Date of Application ) Al 'Fees Paid: State County Date
Permit Issued/Rajeete& (date);4 11 _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)
115 (11-74) Vr qqq4
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 V • MADISON WISCONSIN 53701 0
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: Section T_N, R E (or) W, Township or Municipality
`Lot No. , Block No. County
Subdivision Name
Owner's Name:
s.sc
`Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET SOI L TYPE
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 AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P-
P-
P-
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-
B-
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. Indicate scale
or distances. Give reference point. Indicate slope.
tN
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) Signature
Certification No.
Name of installer if known
Copy C - Local AssViority