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T2; N. R TO SS , ST. CROIX CO WISCONSIN. 4ADJJ ~*BDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Air' j, -ter`--•~- - _ may. PxIC TANK(S) MSGR. CONCRETE ✓ a~TEEL Nt?. of rings on cover Depth DRY WELL tNGHES NO. of width length area ,641 xio0 of line s_ width length- area . dept to top o$ pi a 'G6UwGATE ~ ,RK RATE AREA REQUIRED AREA AS BUILT sciaimer: The inspection of this system by St. Croix County does not imply complete npliance 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 termine cause of failure. EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. G INSPECTOR DATED qI f PLUMBER ON JOB ~ -t- te- j LICENSE NUMBER c z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM Sanitatcy Petc.mit- State Septic NAME Township St. Ctcoix County Locat,LoW 4 0 Section > T N, R./'," W SEPTIC TANK Size gatton6. Numbetc ob CompaAtments Distance Ftcom: Wett ~,t. 12% ot gtceatetc ~stope ~t Bui ding 6t. We-ttand,5 Highwatetc ~ . DISPOSAL SYSTEM Di4tance Ftcom: Wett 6t. 120 otc greaten. 6tope 6t. Building fit. W et.Land,5 Ft. Highwatetc bt. FIELD DIMENSIONS: Wid=th of ttcench 6t. Depth o~, tcock below tite in. Length ob each tine 6t. Depth ob rock overt tiZe in. Numbetc o~ tines Depth o4 tite below gtcade in. Totat .length o j tine65 6.t. Sto pe o6 ttcench in pets 700 Distance between Una 6t. Depth to bedtcock 6t. Totat absotcbtion area it2 Depth to gtcoundwaten 6t. Requited atcea 2 PIT DIMENSIONS: Numbetc o6 pit6 Gtcavet atcound pits yes no Out6ide diametetc Ut. Depth below inlet 6t. 2 Totat absotcbtion atcea 6t z Atcea tcequitced 6t2 rn INSPECTED BY TITLE APPROVED J ''?ATE 19 7 REJECTED DATE 197 - t a . State and County State Permit # 1~~,Fit PLB67 Permit Application County Permit r' , 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:Section r T 23 N, R_J~? E (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 _4, ' uplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES #--'-N-O Food Waste Grinder YES itdO # 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 _A--' Prefab Concrete *Poured in Place Steel Other (specify) _ F. EFFT DISPOSAL SYSTEM: Percolation Rate 1) 2)3) Total Absorb Area 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 -VA No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land 7LA-t4421 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 Certifi~~w NAME C.S.T. # and other information obtained fromE (owner/builder). Plumber's Signature / -~bW/MPRSW# J 4'9' 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). 1/~ 7VI f. E i i I-- r it i i a i a E e c i 5 3 x 3 f 3 3 ~ z E f i ~ a z c Do Not Write in Space Beow/-- FOR DEPARTMENTY i Date of Application Fees Paid: State ff/c, County D to / 17, ` '41211 Permit !issue /Rejeyed (date) -Issuing Agent Name Inspection Yes No Valid# Date Recd 1. county ( ite copy) 3, owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, Wl 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 EH 115 ar 75-7 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES l + DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON !SOIL BORINGS AND PERCOLATION TESTS LOCATION:~'/4, Section , TZ8N, R1 E (or)% Township or Municipality ~ Lot No. Block No. County Subdivision Name Owner's Name: 1' Mailing Address: TYPE OF OCCUPANCY: Residence _-✓K_ No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS .77 SOI L MAP SHEET - - ~ - OIL TYPE 1 - 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/I P -CIL i P- V C 1-71S I_ - St/ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES I I NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED qC) rt - - Vi. e-4 r' ~r K '4 7P;, i err "LAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) 1 idicate on the plan the location and square feet of suitable areas. Indicate number of square.feet of ibso pt ,needed for building type and occupancy. ~ . Fac-10 Indicate scale or distances. Give horizontal and vertical reference 9 i . Indicate slope. )j ~ J I p I I , / r I G~t E ~ I~ I ; l I ~ I 1 I € r fi I i M ! 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) -;-J r-_ FT 0i"), l~ Certification No. Address Name of installer if known U/ rJ Q o r' /1 r CST Signature ti COPY A -LOCAL AUTHORITY v A D1 \i r v4 f/i' _ ,tom , nr~c+.l~l~~l~, dit 2.t3_'I~P~Sai~l { k~ # / Kr REPORT ON SOI! BORINGS ANG Pf:,' " t Al ON ~r r ..OCATiON: _'/4, Section T_N, R E (or) W, Township or Mw c?pality Lot No. Block No. County Subdivision Name Owner's Name: Mailing Address: - TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW _-ADDITION ___-REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS- PERCOLATION TESTS SOIL MAP SHEET' SOIL TYPE PERCOLATION TESTS _ TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL NUM- INCHES THICKNESS IN INCHES BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- P- g._ P- 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) B- 1 r B y~ _ L ,s.. a t S T PLAN VIEW (Locate percolationtests,soil bore holes and suitable soil areas.) Indicate on the plan the locationand square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. 3 e. x. s,y , t 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 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) Certification No. Address Name of installer if known CST Signature rnpv r FII F _CnPY_ Fnp tzrSlt TFCrim