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Sanitary Permit
State Septic
TOWNSHIP t. Croix County
SE. P T I C TA! 1'\*
Si ze gallons. lumber of Compartments
Distance From: We 11 ft. 12% or greater slope ft.
Building ~ft. Wetlands f:
Highwater ft.
DISPOSAL SYSLE:2 __,X,-Tile Field or Seepage Pit(s)
Distance From: Well ft. 12% or greater slope ft
Building £t. Wetlands f.
FIELD uighwater ft.
Total length of lines ft. Number of lines Length of
each line ft. Distance between lines ft. Width of the
trench Total dl-"ft. absorption area a sq. ft. Dept:;
o,~c~f rock below the in. Dp-pth of rock over tile 21 in. Cover
~10.. ever . rock,, Depth of tile below grade S
SZope of
trench in ner 100 ft. Depth t;o Bedrock ` ft. Depth to
,round water ~ft.
PITS
Number of pits ;4;d 'e diameter ft. Depth below inlet ft. Gravel pit: __yes no. Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
%:quare feet of seepage nit area required
Inspected hy: 'L(~ QQ Title c
Approved Date - 197
Rejected Date 197.
K
H 115
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
" Lc 1l3~ r r_,~
LOCATION: '/4, Section T~YN, RJ-e&(or) „1Jownship or Municipality
Lot No. , Block No. _ County -S/- r~"~• X
Subdivision Name
Owner's Name: /W/Zl~/SZCC~ 1f}J0
Mailing Address: oG~r,.i - &&J> s Y~~.,Z
TYPE OF OCCUPANCY: Residence A No. of Bedrooms -3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT X
DATES OBSERVATIONS MADE: SOILBORINGS 57`3,' 2 PERCOLATION TESTS 7-2-7-p
SOIL MAP SHEET _ ~f _ z '
' - - SO I L TYPE - .Z 14-, , ' ' = /'r..: J, r v 1c
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
4t.~
P-
12-
P- _
P S Z- S' z.
See ~0^ z S% ~
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)
Ai tL
B- f 74,
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indi ten bof square feet of absorption area
needed for building type and occupancy. ^~~_~L%~' Indicate scale
or distances. Give horizontal and vertical reference p i ts. In 'cate lope.
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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 an elief.
Name (print) d f 3 - Certification No.
Address _T U
Name of installer if known
i-%TY A -LOCAL AUTHORI i``t CST Signatu
State and County State Permit #
P LB67
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:
B LOCATION: Ll( 4, Section
J/ T1~ N,
R ♦ (or) ~Lot# City_ _
-le
Subdivision Name, nearest road, lake or landmark Blk# - - Village
Township (.E(///^e'ti,- -
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons ,.Z
TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES 1( NO # of Bathrooms
Automatic Washer X YES NO Other (specify)
SEPTIC TANK CAPACITY /C,c= C, Total gallons No. of tanks /
'Holding tank capacity Total gallons No. of tanks
Jew Installation
Addition Replacement Prefa G.
to K
Poured in Place Steel Other (specify)
FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) ,_3 2) 3) v7L Total Absorb Area ~f sq.
"ew Addition Replacement X
*Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _
Seepage Bed: Length-36q Width ~r Depth " Tile Depth No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size y
Percent slope of land f N 4•c,3 Distance from critical slope
r 2~3 ?~G 13k? & rr.J ,
the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
i;^.isconsin Administrative Code, and that I have sized the effluent disposal system from the EH 115 prepared
-)y the Ce,~#fied Soil Tester
!NAME d/wsu•~ ~C.S.T. # --f~ and other information
obtained from / - ( owne
P?umber's Signature 7l)~i
MP/MPRSW# 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 -7 9
Date of Application -79 Fees Paid: State C~oun y Date / -
Permit Issued/Ple0ot~ed (date) / c'), ((-78 _Issuing Agent Name /t 27
Inspection YesNo Valid# Date Recd
1. county (w to copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2 state. (pink ron`r) 4 ni,-ha,, lunar :r
Revised Date 6/1 /76