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• AS BUILT SANITARY SYSTEM REPORT
"_dER
TOWNSHIP SEC. T ' ~N, R i % W
0. ADDRESS ST. CROIX COUNTY, WISCONSIN. l L
3DIVISION /V ~f G/i~ "1 v
LOT_ LOT SIZE -PLAN VIEW "'Ili
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
a--Ve J
C'enle r n,
A,k
rf
-'TIC TANK (S) MFGR.! CONCRETE STEEL
NO. of rings on cover Depth__(- DRY WELL
NCHES NO. of width length area
no, of lines width length ? area `,Z -
depth to top of pipe -70-1 :~REGATE _ ~ r=,~
.X RATE AREA REQUIRED AREA AS BUILT
claimer: 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 ''h z , , •C k
LICENSE NUMBER 2
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
SanitvLy PeAmit-
r State Septic
NAME Town~ship St. Ct oix County
Location~',-,l a6 Sec ~vni T_N,R W
SEPTIC TANK
Size gazzonz. Numbetc o6 Compatctment6 /
Distance Ftcom: Wett L 120 on gtceateA 6tope it
Building 7 wetZands ' ~ .
Highwatek it.
DISPOSAL SYSTEM
Diztance Ftcom: Glee 120 otc gtcea etc 62ape ~ .
Building j it. WetZand/s Ft.
Highwate.k l .7 At.
FIELD DIMENSIONS:
W i R h o~ ttcench
it. Depth a4 tcoch beZvw xti2e gin.
Length o6 each tine it. Depth a6 &ock ovetc tiZe in.
Numbett ob .roes - Depth o6 tite betow gtcade in.
Totat Zength o4 Zine6 it. Scope o6 ttcench 7 in pets 100 it.
i z Distance between Zines_ f, it. Depth to bedAock r 6t.
Totat abts onbtion atcea 6t2 Depth to gtcoundwatetc it.
Requi. Led aAea CC, / S it
PIT DIMENSIONS:
NumbeA o6 pit6 Gtcavet aAound pits ,X, yes no
Outside diametetc Depth betaw inZet it.
~ 2
Totat ab.5o&btionlt ~a t A
AAea &equiAed it2
INSPECTED By ~..rTITLE 1
1 A ~
APPROVED DATE 19
REJECTED , DATE 197.
i
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 TEST
A151-
LOCATION: NW%, Al'tZ, Section, TA%, R6AEr(or) W, Township or Municipality !#/9 M -'nO
Lot No. Block No. County S~• Cofy/x
ubdivision Name
Owner's Name: a ,
Mailing Address: 14J ,J_d
TYPE OF OCCUPANCY: Residence -x No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS wAo e 7f) d PERCOLATION TESTS 6 7F
SOIL MAP SHEET SOIL TYPE ~I 4 4 C 7 cl! T I~•O A
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 jV4 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
46 too", /1,11
l lVo 15' .3 .3 :3 6
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 vp Oi Le ~O
A 1,5."y It 41710'
¢sf 7.
,or 3' 11 -
B- A/7
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square ft of itdl~ areas. Indicate number of square feet or ahsor,, a: ;a
needed for building type and occupancy. [m f Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope.
-
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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) Certification No. y
Address W f W .
Name of installer if known
CST Signature '`Z `v
COPY A - LOCAL AUTHORITY
State Permit #
P 7 State and County _
L ~ 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:
B. LOCATION: ly ) '/4 Ae I- Y4, ection_,Z , T ; R -~E- (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ~/1'lrl9ll~✓c`
C TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family X Duplex No. of Bedrooms 'TAC e r, No. of Persons 71! ~
D. TYPE OF APPLIANCES: Dishwasher X YES NO Food Waste Grinder YES X NO # of Bathrooms--
Automatic Washer X_YES NO Other (specify)
E, SEPTIC TANK CAPACITY /000 Total gallons No. of tanks
"Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement- Prefab Concrete---->(--
'Poured 'Poured in Place Steel Other (specify)
I ;-FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq- ft.
i , Jew_ Addition Replacement *Fill System
Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length'-Width ~ Depth " Tile Depth ',2.4 If No. of Lines o
u
Seepage Pit: Inside diameterZA i( Liquid Depth 4=_ Tile Size
Percent slope of land "7 or.- 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 Soi Tester, NAME ✓E' xe, 1-f O/.. T C.S.T. # S T/and other information
obtained from 14n CA!? 'I! e lop- (owner/builder). 7S'--
Plumber' Plumbers Signature MP/MPRSW# ;~2 Phone #6 Y s Address ~?~~•3s
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
I'
Ib a.
Uj-~
5
1K A; 4-9 -
o . 0-0 ,
oil
6 o w G'-/, ~ r F!~v h'1 p tit /A,a
75 r F2c .41 Se r-jo A C f ~ ti-
t~ e
Ut-
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Q~
r
Do Not Write in Space Below FO DEPARTMENT USE ONLY 0 O
Date
Date of Application / Fees Pai State /c:1, P O Co nt
y 9:2!
Permit Issued/R40we& (date) -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)
AS BUILT SANITARY SYSTEM REPORT
#DDRESS TOWNSHIP SEC. j T 2 7 N, RLj
ST. CROIX COUNTY, WISCONSIN. ,
VISION LOTLOT SIZE %O,4c~e•f
PLAN
Distances & dimensions to meet requirements of H62.20
4;HOG1 EVERYTHING WITHIN 100 FEET OF SYSTEM
Veef
w~u ~ ~ ~--.32--s• ~ 'ter
~eq~e r cT
A,le
0 t `
o J e 4
/Z
w ;y -
)z +ucs~. MFGR. ~d , sG c
I~~iTr'K S CONCRETE STEEL
NO. of rings on cover o.V Depth DRY WEL
32 N0. of width L 0O
of lines length area
___,e width /Z . length W area OD ,
depth to top of pipe 361*
TE
E 'f- s',G AREA REQUIREDAREA AS BUILT
,ner: The inspection of this system by St. Croix County does not imply complete
:ice with State Administrative Codes. There are other areas that it is not possible
°ct at this point of construction. St. Croix County assumes no liability for
)peration. However, if failure is noted the County wil make every effort to
)e cause of failure,
~,.ND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYS
'INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER _
1~_ 4
State Permit # _ -
State and County
i Permit Application County Permit #
t County %SY"~~~t -
for Private Domestic Sewage Systems
ATE AIPP #OVAL REQUIRED t
to App<ovai Received from . State if Required _ State Plan I.D. #
-gWNER OF ~MOPERTY Mailing Address:
I- I
Ito 100~~40 1W '9444
--'b 1G, coon 3 R (or) WLot# ^CitY
T
LOCATIQN: _..~3L
nearest road, lake or landmark SIktfk _ Village -
Subdivision Name, Township
Other (specify) Variance_
TYPE: OF OCGUPANCYc Commercial- Industr(al
Single family _ X. Duplex No. of Bedrooms '~~,l~.S~- No. of Persons
a. TYPE OF APPLIANCES: Dishwasher X YES NO Food Waste Grinder_ YES _NO # of Bathrooms-
Automatic Washer _,K_YES NO Other (specify)
SEPTIC TANK CAPACITY/ D 4 Total gallons No. of tanks -affic.
"Holding tank - capacity Total gallons No. of tanks
Replacement Prefab Concrete X
Addition
New Installation Poured in Place
Steel Other (specify)
_ ft
sq. ~
'if 2) 3) Total Absorb Area
EFFLUENT DISPOSAL SYSTEM: Percolation Rate 11
t m
t *Fill S s e
n
New~_ Addition Replaceme
Y Tile Depth No. of Trenches
Seepage Trench: No. ~ . Feet Width Depth a of Lines ird_O ,
Seepage Bed: Length `Width Depth- Tile Depth t No. w►
Tile Size Ali
Seepage Pit: inside diameter Liquid Depth Distance from critical slope
Percent slope of land_.~~_-
I, the ~undersigned, do . hereby certify that the information 1 have reported' is in accord with Section 1462.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared ►
~j
by the Certified So' Tester, T # .6'5'- 6*Tand other information
NAME _ r-70' OI~►q~~ C.S s I'
obtained from (owner/builder). fi y7 ~9 Phone
MPRSW #
MP/
Plumber's Signature
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
w~ 1.7- Zo 4C.4 CS
49 SLo
.gta,A~04 l
rtac~, /D
4
4 40
w~ t r~ u,e- L 7sr F9o m S«-C
QQ~
Jo Not Write in Space Below FO DEPARTMENT USE ONLY C9
~l?
/Date
- r -
Date of Application ' 7 Fees Pa? : State C o 0 Co~ 17
nermit Issued/Rgjee~ted (date) -y //f Issuing Agent Name Z 14
Date Recd
Valid#
,17
Yes _No
n copy) DIVISION OF HEALTH, R.O. BOX 309, MADISON, W!
)Pv) 3 ownvF (gi
..I aE tst5 ~•`.-~~`"A.#~X4ro..
/r * '74^ '--74 n Mr \'r M to
fJL:VItlJIN LJCN}►tr'i iw►.ir , eJe
t)IVISiON OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
1 REPORT ON SOIL BORINGS AND PERCOLATION TEST"S/ 10I A-14
SectionsI T951. RL7411 (or) WiTownship or MunicipeNty
~'1• ~ t(O/ X _
)t No. Block Mom County
rvlsion me
11111,111111 :wner's Name: ,
+ailing Address:
POI 'YPE OF OCCUP'ANGY: "'Residence No. of Bedrooms
-FFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
-)ATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
')ii CVIAPSHEET SOIL TYPE 1~~O I►~
PERCOLATION TUTS
FVINCHERA
HOURS WATER IN TEST TIME DROP gWATER NUMEST DEPTH CHARACTER OF SOIL SINCE HOLE LE AFTER INTERVAL - 1 THICKNESS IN INCHES IST WETTED SWELLING
IN MINUTES PERIBER l~► o p
~ ~ IBS
P-3 3G /o PI
SOIL BORING TESTS
F
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
(DEPTH TO BEDROCK IF OBSERVI
3FI
- 01"
I NUMBER INCHES 717
e Z 7}y N /O t
#7 jrir11
B '01
Al 7
Alt
7y s~ ~ It ~~it tt y.
LL 0 7A 0,
LAN VIEW (LOcate percolation tests,soiI bore holes and suitable soil areas.)
P
Indicate on the plan the location and square f ~f pI areas. Indicate number of square feet of asortiar~~
needed for building type and occupancy.'
or distanow. Give horizontal and vertical reference points. Indicate slope.
X ~ ! O
1
Y
~ o
J
_ I
i, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedure;
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are col . c:
to the best of my knowledge and belief.
Certification
Name (print)
Address
'game of installer if known
CST Signature
COPY A -LOCAL AUTHORITY
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