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AS BUILT SANITARY SYSTEM REPORT
OWNER 4, y - TOWNSHIP SEC.) S T ':~4N, R C W `
P.O. AD I~ - ST. CRO COI Y, WISCONSIN
SUBDIVISION , LOT I LOT SIZE 1 6 -1 ~ P
w I-D S -3 - c 3
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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SEPTIC TANK(S) G(7 MFGR. CONCRETE /"N STEEL
NO. of rings on covert _ Depth 16, 8 DRY WELL
TRENCHES NO. of width length area
BED no. of lines'- width length area
depth to top of pipe At/it
AGGREGATE L Gt
PERK RATE AREA REQUIRED AREA AS BUILT-
Disclaimer: The inspection of this system by St. Croix County does not 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- - PLUMBER ON JOB y Z r ~ / t ~ - r _
LICENSE: NUMSER -7"
REPORT OF IT1SPLCT10:1--I-MV1DUAL SL JADE DISPOSAL SYSTEii
Sanitary Permit
r Sate Septic i
'ILI ME
mow.:,. U t~~, TOWNSHIP
t. roi.x County
SJR1t'TIC Tn'?S: ~C) .
LJize gallons. miner of Compartments l
Distance From: T•lell
ft. 12% or greater slope f t.
Building / ft. Wetlands f
Highwater ft.
DISPOSAL SYS772:1 Tile Field or Seepage Pit(s)
Distance From: Tiell ft, 12% or greater slope' ft
Building ft. Wetlands f.
FIELD . iliphwater ft,
Total length of lines ft, !lumber of lines Length of
each line eft, Distance between lines ft. Width of the
trench -ft. Total absorption area `______o`__sq, ft, pert;;
.of rock below tile in, nP-pth of rock over tile in. Cover
°ver.rock,, Depth of tile below grade in. Slope of
trench in rier 100 ft. Depth to Bedrock ft. Depth to
Around water £t.
PITS
`lumber 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 by: Title':
Approved Date 197
Rejected Date 197.
EH 1 ■ 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 TIES S
AM, ,
LOCATION: '/4, W, ,Section , Ta& R (or) NQ, Township or Municipality lkoy -
Lot No. , Block No. a0 County <5T -
division Name
Owner's Name: Jim
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOILBORINGS- A00/11 7 PERCOLATION TESTS 616 ) ID
ACC,-
SOIL TYPE -
SOI LMAP SHEET
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME 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_/ 3D ~56C 3c)IL_
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)
/08 > /6R 2_1V .r
16) IC6- /1) C ,r
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitab a areas. Indi ru ber of square feet of absorption area
needed for building type and occupancy. Indicate scale
or distances. Give horizontal and vertical reference points. d to 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 co! Cc!
to the best of my knowledge an belief.
Name (Print)~ Certification No.
Address !
Name of installer if known
CST Signature
y
PL B67 State and County State Permit #
Permit Application County Permit #
-~.-~s.
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:
f
B. LOCATION: '/4 Y4, Section a , T~)5 N, R (o Lot# City
Subdivision Name,. nearest road, lake or landmar Ik# ,Arit~l.~ Village
Dktoi'E Township
C. TYPE OF CU PA Y: *Comfi re vial *Industrial *Other (specify) *Variance__
Single family x Duplex No. of Bedrooms- No. of Persons
D. TYPE OF APPLIANCES: Dishwasher , YES NO Food Waste Grinder ;?!~,YES NO # of Bathrooms.-~2-
Automatic Washer AYES NO Other (specify)
E. SEPTIC TANK CAPACITY /600 Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement Prefab Concrete --X
Poured in Place Steel Other (specify)
EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) otal Absorb Area sq. ft
Nf,wX Addition Replacement *Fill System _
Seepage Trench: No. Lin . _ Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length Width Depth 'y0"Tile Depth No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size IV
Percent slope of land ~a Distance from critical slope _
the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
1'%iisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certi ied So Tester,
NAME C-FF V C.S.T. # and other information
obtained from F - + owner uilder).
Plumber's Signature _ /MPRSW# ~~Phone
Plumber's Address IF, -102 -57 PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
Sc-pt,L
ti
Do Not Write in S ce Below R DEPARTMENT USE ONLY
Date of Application Fees aid: State/6~Co my c' Date
Permit Issued/ (date) Issuing Agent Name
Inspection Yes_,X No Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MAD ON, WI 53701
2. state (pink copy) 4. plumber (canary con0