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• AS BUILT SANITARY SYSTEM REPORT
N, ER TOWNSHIP' LSEC.JL T . ~N, R 7 W
.0. AD RESS _,=ST. CROIX COUNTY, WISCONSIN.
LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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"TIC TANK(S) Ctltl MFGR. CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
'NCHES NO. of width length area
D no. of lines width J5t; length ~ area
t depth to top of pi
~'REGATE i.. '
a RATS ~ AREA REQUIRED -5~ AREA AS BUILT ~ t2
3ciaimer: The inspection of this system by St. Croix County does not imply complete
w: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
stem operation. However, if failure is noted the County will make every effort to
.:ermine cause of failure.
BASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
"INSPECTOR
DATED ? PLUMBER ON JOB,'/ LICENSE NUMBER`
a
'L,r I ,
a REPORT Or IP1SI'i;CTIO?I--I ~~IVli7t 1~t. SE 4ACF DISPMV, SYSTE11
Sanitary Permit
s r State Septic
.VA1 1E
T&WNSHIP
t, C r.oix County
SRDTIC TA'?j: '~v
Size gallons. 'umber of Compartments
Distance From: Well - ft. 12% or greater slope
r Building* ft. Wetlands Alk ft
I'Lighwater -AM _ft.
DISPOSAL SYSTL:1 Tile Field or Seepage Pit(s)
Distance From: Well ft. 12% or greater slopeA.004- ft
Building -41-f t. Wet-lands f:.
FIELD 04$ 1-11ighwater A14 ft.
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Total length of lines eft. Number of lines •Z. Length of
each line L ft. Distance between lines ft. Width of tiic
trench _LZt ft. Total absorption area 4CO sq. ft. Depth
of rock below the LL-in. Depth of rock over tile ~ in, Cover
over.rock MAAAA Depth of tile below grade in. Slope of
trench r... in per 100 ft. Depth to Bedrock N4 ft. Depth to
ground water ft.
tmmber of pits t diameter ft. Depth below inlet
ft. Gravel a-ro nd pit: yes no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
`square feet of see It a r e.d
Inspected 2 PITI e
Approved Date 197.
Rejected Date 197.
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. '/4 _x---'/4, Section , T:AN, R E (oroWW Township or Municipality l -
Lot No. , Block No. rJt%--County1~
Subdivision Name
Owner's Name: e n b,~-
Mailing Address: i -7 tj -;CO I- aNi TI k1nr,) I l~ t(A j
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW 7 < - , A DITION REPLACEMENT
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DATES OBSERVATIONS MADE: SOIL BORINGSt. PERCOLATION TESTS
A
SOIL MAP SHEET - SO! L TYPE - _~F~ -
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 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- A)
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)
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li-AN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Aicate on the plan the locationand square feet of suitable are s. Indicate number of square feet of absorption area
seeded for building type and occupancy. ~ L 16 A~ Indicate scale
or distances. Give horizontal and vertical reference points. /-I icate slope.
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1, 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 toe Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my kn V,wledge and ejief.
11
Name (print) Certification No.
Address~~/'`
Name of installer if known - ' r
CST Signature
-LOCAL AUI HOr iTY
State and County State Permit # PLB 6 7 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: J'/4 Section 17, TN, RE (or) W Lot# City _
Subfision Nam e, nearest road, lake or landmarrkBlk# Village ~"S:~ Township
C TYPE OF OCCUPANCY: *C - mercial Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons_
D. TYPE OF APPLIANCES ~is washer DES NO Food Waste Grinder YES O # of Bathrooms
Automatic Washer A-YES NO Other (specify)
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 otal Absorb Area sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches 11 Seepage Bed: Length Width I / Depth ~Tile Depth No. of Lines_
Seepage Pit: Inside diamet Liquid Depth Tile Size
Percent slope of land 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 Certifie Soil s ,r,
NAME a drldg-f) - - C.S.T. # and other information
obtained from L 17e I/ o ner/builder).
7-p
Plumber's Sign ure P/MPRSW# --+a.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).
ICcc.
Do Not Write in Spac Bel w FOR DEPARTMENT USE ONLY 4Rec'
Date of Application Fees Paid: State Cou y ate
Permit Issue (date) Issuing Agent Nam Inspection Yes No Valid# Date 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH,
P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)