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HomeMy WebLinkAbout036-1052-20-000 -0 ° 'D O 0. ' 30 30 a � p 60 I p � No e M I I N C c c ry' O O o 0 w c= o � .. o c a°7i z 0) (D c c I I y y y O � O O O N C'D O R N N N N y -p .O. C N N � 'a Z 'o Z w�rc c c c _ o U. C LL C V •��� O N 3 x C 0 0 0� o E N U Q Q m O C C M C M 3 8 Z o 3 E �E a O I O N N g fl € O Z r w am am N FM- Z O _O O 0Z v in H c o o o c E p c E 3m O Cl) N C CD M N N O N y O N O .0 N N • C C d w CL 1� y N y N O N C N G CO • f V (. U) � �. s y _U C y _U O Z m Z Z m Z '- I�♦ z z 04. N N O d— 41 N d- d C EL i1) O U G Q o MO d N O y d O co �cca E E I�'c0I Z j N y N 30 c Nr U r ) N r > v 0333 n a z E333 r1m z •N a. IL y I aaa CL 0 0 CO 00 OD I I CA J U Z O rn } Z o CD Z N N � Q h Iz p t CO CO «- j� O m C IL m c d }� y N aI (D N 6 y Q O w N o m Q rn m M d Q Z cn m C I c `.3 y y C O O m 0 C p E O 0 7 Q C, LO o aqi m e a ° a�i F Cl O p l N Cl F- C y C CD 78 c f0 y A d co E C C e0 N r LO r- O w L y Z N 'U y y 0 :: •D 5; 1 M�1 M N r O E C L 41 C N • CO CV O M N O y y 0 A U 0 r` O y O N 10. U O O N fn (L f- N Z N 2 F- r d Cn m n Z N Z 0- 'd CD - I a I a �1 A 0IL j0U)U 0a�)0 I ` I Wisconsin DepatmentofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 77 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Bor strom, Mark St. Joseph Township 036- 1052 -20 -000 CST BM Elev: Insp. BM Elev: BM Description: Section ( rown /Range /Map No: 22.31.17.325B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt, BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLD7 WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil g p [] Yes [M No R Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1783 210th Ave. New Richmond, WI 54017 (NE 1/4 NE 1/4 22 T31N R17W) NA Lod 1 d Par el No- 22 1 �p ►� Gi Gfiu�%� 1.) Alt BM Description - 2.) Bldg sewer length = - amount of cover = Plan revision Required? [ :] Yes 1 No Use other side for additional information. L —_ — SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. 0 Cl) 4) o f G ƒ R 3 E fb « T f � 2 2 7 \ CO $ � S 3 2 9 - ' m � � ¥ ■ o& o � [ ° \ � \ j § � ' ¥ § § § PO ICD © / § � \ C $ = e CL = o e e � ; 0 k � \ g E 3 ' m n i * \ k 3 \ j@ CA k 0 I e � ) �E 7 ' / # 4 f . §Ef 0 � \ :3 E EK2 En om1 { CL �m d \ \ Z: k m «E CL C D \ \ m § , B ! A& E§ { \ ƒ § F \ E / m » $ ] $ '27� \ R ,, § § :03 *E0no 0. Cl CC ' CD ; q @ m }z % - � ~Ea CD :3 M +2 fqC/ \ § \D W Egg \ . /00 % ƒ \ƒ 2 �9 2 C K . 0 % < § \ f E ~ R E q County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you Provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER , [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road �' Hudson, WI 54016 -7710 (715)386 -4680 Fax (715)386-4686 Attach complete plans for syste on paper not less than 8 -1/2 x 11 inches in size. ] County Sanitary, Permit # if revision to previous application SAC. �+ 1. Application Information - Please Print all Informati 0 tion: 3 Owner Na �. -� 3 .. 1/4 1/4, Sec Property Owners ailing Address Irt Number Block Number City, State Zip Code Phone umer (' N ,,_, n� F s ubdivision Name or CSM Number 3Z7 ,/ rle�w Z 7/ 11 Ty u{lding: (check �one) / pity o Viiiage Town of 1 or 2 Family Dwelling - No. of Bedrooms: �j5� %tn � ❑ Public/Commercial (describe use): v " 71n g n O ✓7 ❑ State-owned Nearest Road tl. Type of Pefmit: (Check only one box on line A. Check box on line B if applicable) A 9 /� 4 Parcel Tax Number(s) J 1.[3 Repair [. 3.❑Non- plumbing . ❑ Rejuvenation Sanitation g B) Permit Number Date Issued ❑ State Sanitary Permit was previously Issued Type of POWT System: (Check all that apply) urze In -ground ❑ Mound Sand Filter �� id ❑ ❑ Constructed Wetland ❑ Pressurized In- ground —~ ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other . DlspersaUTreatment Area Information: /V O 0 S A ✓ED — 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Rgg011ett'-I'1,1 511 posed (Gals./day /sq.ft.) (Min./inch) Elevation 'l - 1 Z s4� I. Tank information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks �Ej2n Concrete structed glass Tanks Tanks ❑ ❑ El ❑ ❑ ❑ ❑ ❑ ❑ 1. Responsibility Statement I, the undersigned, assume responsibility for repair / reconnenctior /rejuvenationfinstallation of non - plumbing for the POWTS shown on the attached plans. A l icense is not required for teralift repair or the installation of non - plumbing sa ' ation system. PI Name (print Plum sAnature (i MP /MPRS No. Business Phone Number Pkklf�b s Address (Street, City, State, Zp e) ` /� r �� Il. County Use Only Disapproved Sanitary Permit Fee at e Issued Is ing Agent ignature tamps) ved APPro Owner Given Initial Adverse / l c, � , Determination l � U / dY IX. Conditions of w a F � lYIS � 89 � fQ � 31j 75eqj M as pa q;snw s;uawaa py •iagwnld Aq p , d ewa6euew aad se� paule ao lesaadslp 7c�Z .pue jaliq luonl4o Septic tank, effluent fiit�t dispersal cell must all be serviced / maintained �. 2. All setback requirements must be maintained as per applicable code /ordinances. 4M44-1� ST. CROIX COUNTY WISCONSIN ZONING OFFICE ■om• ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 �y --� (715) 386 -4680 AFFIDAVIT OF RE- CONNECTION Property Owner: ✓t ��-°'� Address:_ Day time phone: Parcel I . D . # //�� Legal Description of property: A A Y", Sec. �,A, T. _-3/ N. o ` R. W., Tn. of 57c 17 / , CSnYP" 3D !SY St. Croix County, WI we . I ��, . 1 As owner of the above described property, I acknowledge that the septic system serving this proposed ? bedroom residence is undersized by current code standards, but otherwise meets all requirements of State Statutes, Wisconsin Administrative Code and St. Croix County Zoning Ordinances. I understand that the issuance of a sanitary permit to allow the re- connection of the existing system does not imply that the system will function properly after it is placed in service. I also acknowledge that I will inform any future parties interested in purchasing this property that this permit was issued for the re- connection of an existing septic system and not for the installation of a new system. Signature: Date : t m'P II 'a0 PLOT PLAN PROJECT Mark Boros mm ADDRESS 146 90th ave Clavton Wi. 54004 NE 1/4 NE 1/4S 22 /T 31 N/R 17 W TOWN Stanton COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 DATE 4 -14 -04 BED ROOM 3 CONVENTIONAL XXX IN -GROUN RESSURE C NVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gal EX LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers BENCHMARK V.R.P. top of well ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P Same as BM SYSTEM ELEVATION E st. 96' > 100' to PL Garage 3 bed house well y �/J 75' Est. 54'X >> 50' to 50' 3 PL- 30' i St Drivew a 150' 210th ave ❑ ❑ ❑ o � € € �0Z0 o g a Z J O Z � � � � 16 �` � � a LL .s Z a o rd c4L LL' � LU € E < 2 .1 Q c > zV w J W L L O � am �L M TX g$ 2E E �i� �o W j r © z w ZZ p w Z �-- ? ° W D wW CD O Z Q Z U) N W O v W p w U3 =Z Q D _ �_ a o r oc O r �� Oo M L O - i m 0 O ° > U W w AA J LL1 \"y r n _ w LL �� 0 W O 41 0 64 w Z 2 Z Q z CL � � 3 O 0 a h— ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address _ -_- G� 4,4,�7 (Verificatio- equired from Planningbepartment for new construction.) City /State Parcel Identificati Number Ld�o 0 y LEGAL DESCRIPTION X. ` d Property Location. ' /a, ' /�, Ser., TrN -RW, Town of a ` Subdivision . Lot # �. Certified Survey Map # - 7 0 - _ , Volume , Page # Warranty Deed # 7o oZ L) , Volume 2 Z a Page # ' Spec house ❑ yes ,9 no Lot lines identifiableO yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. submit to St. Croix zoning Department a certification form, signed by the owner and by a The property owner agrees to g Departm maste,rplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification 91GATU" ' at your septic system h.-- been maintained must be completed and returned to the St. Croix County Zoning Office within 30 he three year expiration date. / /oy O APPLICANIF DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of M described above, by virtue of a warranty deed recorded in Register of Deeds Office. (, 1 —/ A/ 0 I NATURE F APPLIC DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. «« Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: Sec. T R `� W, Town of �jf �� St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No `X (if no, skip next line. Approximate volume or le th of time: r– gallons minutes Capacity: Construction: Pref3t Concrete Steel Other Manufacturer (if known) : aw c �� Age of Tank (if known): (Signa ee e) ) �C – (N — ame)Z Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code, - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adui. C de (except for inspection opening over outlet baffle). �ZD Name ignature MP /MPRS PLOT PLAN PROJECT Mark Borastrom ADDRESS 146 90th ave Clavton Wi. 54004 NE 1/4 NE 1/4s 22 /T 31 N/R 17 W TOWN Stanton COUNTY ST. CROIX c.. MPRS Byron Bird Jr. 220527 DATE 4 -14 -04 BED ROOM 3 CONVENTIONAL XXX IN -GROU RESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gal EX LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers hk BENCHMARK V.R.P. top of well A SSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.p. Same as BM SYSTEM ELEVATION Est. 96' > 100' to PL Garage 3 bed hous well qr 75' Q -.7 Est. 54'X ' > t o � 30' PL 30' 3r St Drivew Fty 150' 210th ave • .�3i2 71 �8 CERTIFIED SURVEY MAP e� 610. ......... . .643-34 IRON PIPE SET AT -17 i y NE CORNER SFC. 22 -31 - c0 10.001 ACRES w � �• do • ED • 3302 89 r ld'E - c c 975 ti Y 22 N 612.04 N MBEu O' COµµEtl O O R*plflsr of Deeds 40 Sb Croix County, N (.0 N 1& Wisconsin 'tr d. 1 • O+ � O 10.001 ACRES 33.02 3 so3.7j' S89'50'10" E 646,77' 1293.56' • i>D �g cn N o `D � _ BUILDING t = SETBACK LINE N N w cli 3 18.188 ACRES N O • 13� 1296.67' $T X402° N 33.02' N89 `��'� N 89 °50 10 W 648.42 I 615.23 2 O i6 ROADWAY —+ EASEMENT t` I to Cn Go t `O u> • IRON PIPE FOUND '` u' 4 0 IRON PIPE SET �N 10.001 ACRES ry ALL LOT CORNERS . . N STAKED WITH I "X 24" IRON p PIPE, WEIGHING 1 -13 LOS./ 3, �`' �� ° cn LINEAL FOOT. Z Is.9 N 89 °5055 W 649,96 Q RT H • ; SCALE -- 1" =300 66` Volume 1 Page 124 SEE OTHER SIDE U 2y27P y5y ?424x5 tt STATE BAR OF WISCONSIN FORM 2 - 2000 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., MI This Deed, made between Neal A. Peterson, a single person RECEIVED FOR RECORD Grantor, 10/03/2003 10:00AN and Mark J. Borestrom and Carrie Borestrom, husband and wife Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and warrants to Grantee EXEMPT I« the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00 (if more space is needed, please attach addendum): TRANS FEE: 289.50 That art of W' /2 NE1 /4 NE 1/4 Sec. 22-T31N -1117W described as follows: COPY FEE: P CC FEE: Lot 1 of Certified Survey Map recorded in Vol. 1 of Certified Survey PAGES: 1 Maps, page 124 as Doc. No. 3 St. Croix County, Wisconsin. Recording Area Name and.$' ..> i 4 -s \ 031_AND ATTO ^ N EY AT LAW P.O. EOX 359 HUDSON, W{ 54016 w: 036 -1052 -20-000 Parcel Identification Number (PIN) This is homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this (iV day of October , 2003 * * Neal A. Peterson AUTHENTICATION ACKNOWLEDGMENT Signature(s) Neal A. Peterson, a single person STATE OF _ ) ) ss. -- - - -_.. -------------- ___. —_ .__..- __ County ) authenticated this day of October 2003 Personally came before me this _ day of the above named * Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, _ _ __ _ _ _ to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same, THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland, Attorney at Law 304 Locust Stree Hu dson, WI 54016 Notary Public, State of My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) * Names of persons signing in any capacity must be typed or printed below their signature. INFO -PRO (800)655 -2021 www.infoprofonns.com STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 2000 chp -655 - COOLhouseplans.com Page 3 of 7 q r W Y «rA t eq http: // details. coolhouseplans .com /details.html ?pid =chp- 655 &FoundID= 21 &sid =chp3 6/9/2004 m s.' ` i � ,� N a1 � ,� � � s, � � �- S ,' 9� a _____ �-� a �� S _ � - a T �' �, xi., s` d P ��y{ a V _ '� �` ^I �. 1 `� N �. � r. f C. �.n � � �; � T ^+ � x. �k CF-1 F 0 • V"1 t' wrs.r'rrr x so 1 C I i I • AS BUILT SANITARY SYSTEM REPORT r - TIER e-" , TOWNSHIP 51W,; SEC. TAN, R ,0. ADDRESS ; ey ,br, , ST. CROIX COUNTY, WISCONSIN. 73DIVISION , LOT LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ?TIC TANK(S) MFGR. joywy es Cerne.-ma ONCRETE STEEL NO. of rings on cover Depth DRY WELL _NCHES NO. of width length area J no. of lines Z width 1 2I length q q" area 1)z depth to top of pipe Z`7 � L X �_K RATE L- 1 AREA REQUIRED i Z AREA' AS BUILT ► 2 _ .:claimer: The inspection of this system by St. Croix County does not imply complete pliance .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 .tem operation. However, if failure is noted the County will make every effort to ermine cause of failure. �ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. ~ INSP R DATED 7 — Z- d` 7 g PLUMBER ON JOB C k9 LICENSE NUMBER /S-(, z REPORT OR INSPECTION INDIVIDUAL SEWAGE SYSTEM Sanitaxy Pexmit �! State Septic L ,. NAME Towndhi p 't_ St. Cxoix County Locatiory % au %, Sec ion T IN, R// W SEPTZ TANK Size z gattons. Numbers o6 Compaxtmentz Distance Fxom: Wett 6 it. 120 on g x eatex ztope Ira- St Bu.itd.ing I it. W ettands n Highwaten DISPOSAL SYSTEM Distance Fxom: Wet % it. 12% on gxeatex istope r fit. Bu.itd.i.ng it. Wettandd F t. H.ighwatex Ila it. FIELD DIMENSIONS: Width o6 txen it. Depth o6 x ock below t.ite Z� in. i 1 �£y Length a each tine g � � it. Depth o6 xaclz oven t.i.2e '� .i n. b Numbers, ob tines Depth of t.ite below gxade tin. T otat length a ineb �a it. stope o6 trench n pen 100 � . Distance between tines , Z2 b t. Depth to bed&ock Totat abs oxbt.ion axea 6t Depth to gxaundwatex fit. Requixed axea i t 2 PIT DIMENSIONS: Numbers a6 pits GAavet axound pits _ yes no Outside d.iametex it. Depth below .inlet it. 2 Totat abboxbt.ion axea 6t z A Axe.a xequ.i&ed it rn INSPECTED TIT 1 2 APPROVED ,DATE f 197,'. REJECTED ,DATE 197 P LB67 State and County State Permit # 1 Permit Application County Permit # 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: 9 04n R- Y) S B. LOCATION: n ' / Section 2_t— T N, R� E (or) Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township 57'/9_49P C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIA C S: Dishwasher YES NO Food Waste GrinderYES N�0 # of Bathrooms Automatic Washer AYES NO Other (specify) E. SEPTIC TANK CAPACITY / QQeo 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) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) �J 2) 3) Total Absorb Area )) 2.. S sq. ft. Newt/ Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenche Seepage Bed: Length 9 y , Width 1 2 I Depth 0 �' Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land S Distance from critical slope Y 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 T t NAME C )4L vin vv erS C.S. and other information obtained from own uilder). Plumber's Sign � Phone # y Plumber's Address PLAN VIEW:. Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). / /00 I r cnG J Iii . �� •. lam' Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application — Fees Paid: State /O 00 County • O O Date Z �= Permit Issued /Rejected (date) /� Q Issuing Agent Name Inspection Yes -No Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) � Revised Date 6/1/76 EH., 115 , WISCONSIN DEPARTMENT OF HEALTH AND SOCIA L SERVICES f DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION '/4, '/4, Section ?nj, T3�1\1, R L2 E (or(WRTownship or Municipality 57e91 Lot No. , Block No. County Ste. C;iZy'iJi Subdivision Name Owner's Name: r Mailing Address: TYPE OF OCCUPANCY: Residence ,�� No. of Bedrooms �— Other EFFLUENT DISPOSAL SYSTEM: NEW AD ITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS — 7 PERCOLATION TESTS SOIL MAP SHEET SOIL TYPE 5— PERCOLATION TESTS TEST I 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 MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 o s Pa y� / 1 P -3 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) CPC o- 6-,Z a 5 , L" 5 YC o� 1 • , Z a S, - 26S 6 ^2-6 S, 0- 7 45K PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable r s. Indicate number of square feet of absorption area needed for building type and occupancy. ) 2 S' Indicate scale or distances. Give horizontal and vertical reference points. ndicate slope. 1 00 !J s s t N o ti a A � o I I —A 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) L u l k a w ek - _ s C ertification No. Address Name of installer if known CST Signature COPY A —LOCAL AUTHORITY