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REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitatcy PeAmit-
State Septic
NAME Towntship St. Ctoix County
Location% o6 Section T_N,R/ W
SEPTIC TANK
Size Zl~ gatton6. NumbeA ob CompaAtments
Di,6tance FAOm: Wett s _61_. / 1,2% on gtceateA zZope. ~t
Bui ding -F bt. Wettands ~ .
HighwatvL ~ .
DISPOSAL SYSTEM
Diztance FAOm: Wett 12% on gneateA 6tope bt.
Building _6t. W et.Landt6 Ft.
H.i.ghwatetc 4t.
FIELD DIMENSIONS:
Width o6 tAench 6t. Depth o6 Aock below ti..Le in.
Length ob each tine ' 6t. Depth o6 tcock oveA t,%..-e Z. in.
NumbeA o6 Una Depth o6 tite betow gtcade `2 in.
Uwl-
To tat Deng h o Una Slope o4 tAench in pen 100 6t.
Di, stance between tines 6t. Depth to b edt o ck 6t.
Tota.L abzotcbtion atc.ea j/:,)} jt2 Depth to gtcoundwatvL 6Z.
RequiAed atcea i 2
PIT DIMENSIONS:
Numbetc o6 pits GAavet aAound pits ye/s no
Out.6ide diameteA 6t. Depth be.-ow intet ~ .
2
Totat abtsoAbtion ~a bt A
11 .
AAea %equited ~ 6t2
t-
l
INSPECTED BY TI TL Ell
APPROVED T('(,/~ DATE 197
REJECTED DATE 197`
<LL
I
EH 115
WISCONSIN DEPARTMENT OIF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND pERCO~LATION TESTS
LOCATION ~ '/4, 1~ "i/4, Section T Affi, R Z-j' E (or) ownship Municipality
Lot No. Block No. , 11117 w' d'' 'GG S County °5 /ili' 1 X
i~ c1/-//✓/~ Subdivision Name
Owner's Name:
Mailing Address: 7W/1//vS?1
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW A ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS- PERCOLATION TESTS /1-~~ ;07
SOIL MAP SHEET SOIL TYPE -511-7 Z e,4197
PERCOLATION TESTS". ~Lla'~~.•~
TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
CHARACTER SOIL SINCE HOLE HOLE AFTER INTERVAL
6ER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
t E R 13, -
- Z7 r-OWIV 5'iL T fV U y,~ d /Y J10
P~ 273e i~ sV siLy" L dl-;) 2 / l/ e 7-L/
i9ed" _V_4 A14 _5V ;r
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)
JJ
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PLAN VIEW (Locate percolation tests,soil 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. / 4e ' S = 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) WA/_/ ,,e E~ a Certification No. C
Address
Name of installer if known
CST Signature
I~•OPY A - LOCAL AUTHORITY
.t
~ ~ ~ ~ ~ State and County State Permit #
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:
c .0 -3
B. LOCATION: Section T~N, R E--(vr" Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
ownship
6 /Ul G L S
C. TYPE OF OCCUPANCY: -6e~unecciaL- <-ttrdu"Tai-- ~E~ther ~snarifvl '~tfariance_
Single family duplex _No. of Bedrooms No. of Persons
D. TYPE OF APPLIANC S: Dishwasher X YES NO Food Waste Grinder YESNO # of Bathrooms_
Automatic Washer YES NO Other (spec _
E. SEPTIC TANK CAPACITY? p O J Total gallons No. of tanks
an Total gallons NO. Of-t@ 6---_
New Installation Rrptm-enTmrt--- Prefab Concrete -Addstmuir ourP ed-m-Place- Stee`----- Other (specifV)-----
FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _J 2)_Y6 3) _!!Z Total Absorb Area sq. ft.
Deptb_- _ B fr -
See
-
Seepage Bed: Length _F-or-Width_ Depth Tile Depth a5 No. of Lines
Se --diameter ♦ 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 ~~)~1~' ' Ci and other information
_ ~1 L)~ C.S.T. # ~obtain from (owner/builder). P b s Signat re C-r,~~ct~Qs MP/MPRSW# Phone
s Address '1
PLAN VIEW: Provide sketch below of system ,1e direction of slope and all distances in accord with
H62.20, including well).
~3f1,T 74177 O/ ! 7
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Do Not Write in Space ,Below FOR DEPARTMENT USE ONLY
-'T T~ • r
Date of Application C' Fees Paid: State % C, C(-) C unty- C' Date L
Permit IssuedA,@jeeted (date) Issuing Agent Name _
Inspection Ye4No Valid# Date Recd
1, county , copy) 3. owner (green py) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)