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AS BUILT SANITARY SYSTEM REPORT
OWNER ~~1`i?/y' TOWN SHIP~jG'k'jltif;,,,/ SEC. TAN, R~ ~GJ
P, 0. ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOTI=S LOT SIZE
PLAN VId4a " ' -
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100FEET OF SYSTEM
0
f- - - - - - - T y yr_tvi
EX iS Ten)c
r
SEPTIC-TANK(S) MFGR. CONCRETE X STEEL-
NO. rings on cover _ Depth DRY WELL
TRENCHES No. of width length area _
BED no. of lines width --/T, length' area
de'pth to top of pipe ( 6 Ye r~
AGGREGATE
PERK RATE lC, AREA REQUIRED AREA AS BUILT
DISCLAIMER: The inspection of this system by St, Croix County does no imply
complete compliance with State Administrative Codes_ There are other areas
that it is not possible to inspect at this point of construction. St. Croix
County assumes no liability for system operation. However, if failure is
.noted the County will make every effort to determine cause of failure,
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
DATED
,;~7,; )
PLUMBER ON JOB
LICENSE
r/y a ,
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
SanitvLy Persmit
• State Septic
NAME Townes hip St. CAo i x County
Locatioj;&% Section 2~'r N, R
SEPTIC TANK
Size gattonz. Numbers o6 CompaAtment6
Di.stance Frsom: wett it. 12% on grseateA zZope it
Building it. Wettand~s it.
H,i..gh.watvL ~ .
DISPOSAL SYSTEM
Distance Fnom: WeU it. 12% oA gteatet stope it.
Building it. Wettand, - Ft.
Highwatetc ~ .
FIELD DIMENSIONS:
I
Width o6 tAench it. Depth of rsock below tite in.
k
Length ob each tine it. Depth o6 Aock oven tite in.
Numbers o6 tines Depth of Cite betow grade in.
r
Totat .length o6 Zinez it. S.-ope of tAench in pen 100 it.
Di, stance between Unez jt. Depth to b edrso ck it.
Totat absoAbtion area 6t2 Depth to grsoundwateA it.
RequiAed atcea it2
PIT DIMENSIONS:
NumbeA o6 pits Gtcavet aAound pith yes no
Out.6ide diamety ~t4 Depth be.-ow ,i.ntet it.
Z 2
Totat abzmbtion,'arsea it z
A
Atcea Aequi,,Led it2 rn
INSPECTED BY TITLE
APPROVED , DATE -197-.
REJECTED ,DATE 197
e
s;
EM 1.15
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 TESTSn r
LOCATION $'/4, Section , N, R J SOW W, Township or Municipality-
a ~l/=-L~ -
Lot No. Block No. 1116 County _S - ca /A
ubdivision Name
Owner's Name: JA M` L44/~'~-/ -
Mailing Address: (X
- ~ S~),7 U&16,t
TYPE OF OCCUPANCY: Residence - No. of Bedrooms 4_C_ Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION --REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 406- , PERCOLATION TESTS A06-
SOILMAPSHEET SOIL TYPE U
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 SE P 23C RE 'It I
P
s-
40
N
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)
f/ CM 3'A/ rN
B 1.
" Py CLAY r
B
-:230 CLA tC} r 541YQ
B ca( 7
off
910,0 CiA
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet QQf,suitable areas. Indicate number of square feet of absorption area
needed for building type and occupancy. `y~C~ S f Ta 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) ~ ~ T P A 1~1 /TTY F"~i DT Certification No.-
Address _ r 1 )"(WA 02 0 h f~1/`s C~_ / -
Name of installer if known -_,M( p / A t`t l jj,ms/ ; ~~T!Z~7
CST Signature " ' L
State and County State Permit
PL867 Permit Application County Per .t #
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:
TAM K~ Rodrz5 WI,4sia& c°_
W Lot# City
B. LOCATION: ly_F '/'/4, Section , T N, R
21006 * -
Subdivision Name, nearest road, lake or landmark Blk#40~1Nf&RC/Al, Village
SMCEr Township zD
C TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family _X Duplex No. of Bedrooms .1 No. of Persons _
D. TYPE OF APPLIANCES: Dishwasher YES _ NO Food Waste Grinder YESNO # of Bathrooms
Automatic Washer 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)
EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _J0 2) _/C _ 3) /0 Total Absorb Area_ sq. ft.
New-k 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 diar' Liquid Depth Tile Size p
Percent slope of land Distance from critical slope ~Q~ A_~i~L~'`~
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 A10ARCQ A I R4ESTAD r C.S.T. # and other information
obtained from 71A M- (owner/builder). /
Plumber's Signature I*/MPRSW# -3~ Phone
Plumber's Address A~" PP o
PLAN VIEW: Provi;,e sketch below of system (include direction of slope and all distances in accord with
H6'-,a7, including well).
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Do Not Write in Spa Bel w FOR DEPARTMENT USE ONLY , 0 /J J
Date of Application Fees Paid: State 0, n L~ County G_~ Date / -
Permit Issued/Refeeted (date) _ - 71 -Issuing Agent Name /
inspection Yes-,-Po Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
,tp „k copy) 4. plumber (canary copy)
Revised Date