HomeMy WebLinkAbout012-2001-70-000 (2)
n cn O 3 v n `r1
c 3 -1
-0
CD co H`
0 2) (n 0 N) (D
S 7 C OD a) ~p O (.J N ICI
d CD CD M -0 (D O. Vl (n ON r7 lA\
03
N CD 3 N N (D O r~~ 1
O CD p Q N - O O R O
O m C CD Q 0 W O
Oo p V O
3 N co
p
GI C V O~
o a C D c rn
CD cn CD (n a :7
M = N W
n~ O rn ~V
o m
CD
cn z
O -4 -4 0 ! y C c
w w 3 c
o -D -D (N
N S 2 w
O O <n c~ A cD
O = '
D ~ lr
V
N
a
z -T
N
o ' ~I
z co O
z Q
D d
0 :T
CD
N N
CD
c N a I
w iu
a ~
z CD -j to
O p A Z CD
z O
N A
CL
a.
' Zz -1 •p
M ~ < O
CL (D z
1 A
O z
V
y z
(D 41
w ~
I
0) m cu a) D
N m N v a
_.~a~-u c" :E
f m °o m -n
m v c
_ m W (n CD
M. v' z p
O F4.< = O
0 0)
O K 3 N
a N N
' ro -N i
N s o
m :oI O I
:3 -0 y :3 lzt
0 -0
ICS Cy~
c
o
-4
Q1 a)
7' S a e
0 CD - =r
c om~ 00
CL - a
3 N CO cn
c O
wSoI° oa
IP v =3 o
o w
O
N
og O ~ N
6 CD
° a
ti
• AS BUILT SANITARY SYSTEM REPORT
-ER TOWNSHIP` SEC. T__rN, R~ _W
o. ADDRESS ST. CROIX COUNTY, WISCONSIN.
DIVISION , LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
R
' z 7--
-'TIC TANK(S) P MYGR. y CONCRETE STEEL
NO. of rings on cover. Depth DRY WELL
":INCHES NO. of width length. area
J no. of lines width length area
depth to top of pipe
,REGATE
ru }
-a RATE j AREA REQUIRED AREA AS BUILT
-ciaimer: The inspection of this system by St. Croix County does not imply complete
_.pliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
:'.tem operation. However, if failure is noted the County will make every effort to
,ermine cause of failure.
_~ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
-''INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER
1
REPORT OF IIISPECTIO.D-- I~DDIJIDUAL J Li4AGE DISPOSAI, SYS' y,,J-i
Sanitary Pernit
r State Septic /
IE TOWNSHIP
bt. Cr01"
County
SEPTIC TA'?I
Size gallons. `Dumber of Compartments
Distance From: We 11 ft. 12% or greater slope ft.
Building` ft. Wetlands f~
Nighwater ft.
DISPOSAL SYSTL.:1 Tile Field or Seepage Pit(s)
Distance From: t1ell ft. 12%,or greater slope- ft
Building ~ft. Wetlands f
FIELD Highwater ft.
Total length of lines ft. Number of lines Length of
each line ft. Distance between lines ft. Width of the
trench _.._ft. Total absorption area sq. ft. Depth
of rock below file in. Depth of rock over tile in. Cover
-raver. xoc1:: Depth of the below grade in. Slope of
trench in ner 1,00 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS
Number of pits Outside diameter ft. Depth below inlet
ft. Gravel around pit: __yes no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required.
`square feet of seepage nit area required
Inspected tiy: Title
Approved Date 197
Rejected Date 197.
j
State and County State Permit # -
PLB67 Permit Application County Permt
' --111W 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:
B. LOCATION:; Section T=om N, R V (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
_ _W 41e,10 Township,
C. TYPE OF OCCUPANCY: -Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms y No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms.
Automatic Washer -YES NO ther (specify)
E. SEPTIC TANK CAPACITY L~ -Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation _ X Addition- Replacement- Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)_" 3) Total Absorb Area sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length. / Width L-,2" Depth s„ Tile Depth 2- y ff No. of Lines _
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land Lj% V 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 C.S.T. # and other information
obtained from (owne b er).
Plumber's Signature(%y~ M MPRS Phone
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
C Ov ~ p `t
G~100
1 v~'
ti
a
Do Not Write in Space, Belo r, R DEPARTMENT USE O.,yLY
Date of Application Fees Paid: State JJ C X~~ Date
Permit Issued/Re (date) -Issuing Agent Name /
spection Yes~No Valid# Date Recd
ounty (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
(pink copy) 4. plumber (canary copy) Revised Date 6/1/76
EH 115
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: k, '/4, '/4, Section , T N, R/_/ 4 (or) W, Township or Municipality I'411
Lot No. , Block No. County
G Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms S Other
EFFLUENT DISPOSAL SYSTEM: NEW Y--ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS A PERCOLATION TESTS
SOIL MAP SHEET SOIL TYPE
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
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P_ 7)
' i a S
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,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of suitab_ I ,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 sl pe,,,,
10
i { ~ i ( t IGCV
i-- - -t _ _ 0
I ' f { i f , ~ I ' 1 I
I _ s I _ i ~ I a I ~ ~ I I
,
f V ,
I - - I - - l
r
I ~ I~ ~ ~ i I ! ` I i I ; i I
! ;f ' _ _ f - -~--_4 -----I
~
I I f !t ` 1
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.
Certification No.
Name (print)
Address
Name of installer if know _
CST Signature
COPY A -LOCAL AUTHORIT-'(