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REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM 4'
an,itah.y Persm.it-
State Septic/
NAME Township St. Crso.ix County
Location o 6 fd' Section T_N, R W
SEPTIC TANK
Size ga.e.eonz. Numbers o6 Comparstment.
Distance Frsom: We.e.e 6~. 120 on grseaters 6tope 6t
Bu.i.ed.ing 6t. Wettand~s 6t.
DISPOSAL SYSTEM Highwaters ~ 6t.
Distance Frsom: Wet.e 6z. 120 ors gAeatet ztope 6t.
Bu.i.eding 6t. W et.eands Ft.
H ighwatvL 6 .
FIELD DIMENSIONS:
Width a6 trench 6t. Depth o6 tock be.eow tite in.
x Length o6 each tine 6z. Depth a6 rsock oven t.ite in.
Numbet o6 tine/s Depth o6 tite be.eow grsade in.
Totat tength o j Z inez 6z. S.eo pe o6 trsench in pen 100 6z.
1
Di.btance between Una 6t. Depth to bedrsock 6~.
Totat ablsanbtion arsea 6t2 Depth to grsoundwaters 6t.
Requ.irsed arsea 6t2
PIT DIMENSIONS:
Numbers a6 pigs Gnavet arsound p.itz yeas no
i
Out6 ide d-iameten 6t. Depth below inlet 6t.
2
Totat abzmbtion arsea 6t z
A
Atea nequirsed 6t2 rn
INSPECTED By TITLE
a
APPROVED , DATE 197.
REJECTED DATE 197
.
EH f 11
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: L--L-'14, ILL, /a, Section , TAN, R ~L41or) W, Township or Municipality
Lot No.
~ [ Subdivision Name
Owner's Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms -.3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
F DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET Q SOIL TYPES
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_ I tip
P-: L
L A) 13
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) T .51
7 C~ -fS >~ySL a' - L <
S, St ° ~ys4 .1y - jC(. ~Y SSG
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16 7- 5, j
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. G ~5 Indicate scale
or distances. Give horizontal and vertical reference points. Indicate slope. 67
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I, the undersigned, hereby certify that the soil tests reported on this form were mad4,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 kn wledge and bel
Certification No.~- 5-~
Name (print)
Address i-. s?.C^J 4 .s SC
Name of installer if known
CST Signature cz,
' `j'"
State and County State Permit # __..9
Permit Application County Permit # _
PLB67
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:
i
B. LOCATION: SG_- '/4 Alk,l '/4, Section TN, R (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: *Commercial *Industrial "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-1-
Automatic Washer -4YES 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 ISPOSAL SYSTEM: Percolation Rate 1) , 2) 3) Total Absorb Area_(dj!;12 sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin . Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length ~ Width Depth Tile Depth No. of Lines__
Seepage Pit: Inside diameter 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 Certified Soil Tester,
NAME s C.S.T. # and other information
obtained from ! (owner/builder).
Plumber's Signature C1~ MP/MPRSW# !5 G> 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).
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Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application " Fees Paid: State County Date -
Permit Issued/R_. jes (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)
Revised Date 6/1/76
I