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HomeMy WebLinkAbout040-1183-50-000 Wiscor ain Department of Commerce County: .� PRIVATE SEWAGE SYSTEM St. Croix Safety,!nd Building Division INSPECTION REPORT Sanitary Permit No: 506391 0 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: Swanson, Roger A. I Troy, Town of 040- 1183 -50 -000 CST BM Elev: Insp. BM Elev: BM Descrili Section/Town /Range /Map No: Q /( . D eb_1+L 36.28.19.746 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark D Alt. BM W 2lo a Aeration Bldg. Sewer r X77 AJ Holding SUHt Inlet -- TANK SETBACK INFORMATION s t outlet 9. �- TANK TO P/L WELL BL`_ Vent to Air Intake ROAD e G 1 ✓ lvK. ✓ do C �� Septic L�( S/ / AJ6 r - G 1� Ci ✓ Z 0 ! He ader /M an. `O Aeration Dist. Pipe 3. 93 Holding Bot. System �Z 73 Final Grade PUMP /SIPHON INFORMATION .fwd Manufacturer Demand St Cover GPM ,�— Model Number �lv! TDH Lift Friction Loss Syste Head TDH Ft — Forcemain Length I Dia. Dist. to W.6 SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 3 SETBACK SYSTEM TO P/L BLDG WE LAKE /STREAM LEACHIN Manufacturer: INFORMATION CHAMBE OR Type f System: t > / U Model Number: DISTRIBUTION SYSTEM HeadeCMyn(fol� IDistribution x Hole Size x Hole !pa Vent to Air Intake Pipe(s) I Length Da Length 6/0 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 -, r , q✓� [� Yes, No Yes i No COMMENTS: (Include code discrepencies persons present, etc.) Inspection # / Inspection #2: / / Location: 54 Riverside Drive River Falls, WI 54022 (SE 1/4 NW 1/4 36 T28N R19 Danate Park Lot 30 No:: 36. .228.19.746 1.) Alt Description s = � ow 2.) Bldg sewer length = �- /1/ c // �{�C�ll� - amount of cover = s Plan revision Required? J Yes v� ✓ Use other side for additional information. / t/+�� ( � 7( � SBD -6710 (R.3/97) Date Insepctor's ignature Cert. No. ' �e IIa.C�rY1eY1�' commerce.wl.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 i s eo n s i n Madison, WI 53707-7162 Sanitary Permit Number (t be filled in by Co.) Department of Commerce Sanitary Permit Applicatio State Transaction umber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms f Project Addre (if ifferent than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary p urpose in accordance with the Privacy Law, s. 15.04 1 m , Stars. I. Application Information - Please Print All Information Property O er's Name REGFIV 113 Parcel # Property Owner' Mailing Address Property Location Govt. Lot City, State Zip Code fione niffiYei /,, Section _ ( circle n� r' T N; R o a H. Tyre of Building (check all that apply) Lot # 1 or Family Dwelling - Number of Bedrooms Subdivision Name Block # � ❑Public /Commercial - Describe Use _ il ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Town of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System g Rep y g Ys (explain) ❑ Treatment/Holdin Tank Replacement Only Other Modification to Existing System ex lain ) B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber El Permit Transfer to New List vious P t Number nd Date Issued Before Expiration Owner C IV. Type of POWTS S stem /Com onent/Device: Check all that appl Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ t- Gra � ❑ M/ol0 > 24 in. of suitable s it Mou n 4 in. o suitab e soil ❑ Holding Tank ❑ Other Dispersal Component (explain) V�-- t retrc ent Device (explain) G / —w V. Dispersal/Treatment Area Informatio Design Flow (gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required (sf) Dispersal Area Pro sed (sf) System Elevation 1/1 s' _ VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units d n ? v d y New Tanks E xisting Tanks— f � " ° C 6510 Septic or holding Tank x r T VII. Respogsibility Statement- I. the undersigned, assume responsi lity for installation of the POWTS shown on the attached plans. Plumber's amc (P ' t) � Plumber's ignatu 7MPRS Number Business Phone Number Plumber's Address (Street, City, Stat Zip Code) VIi VIII. County /De artment Use Onl Approved Disapproved Permit Fee tnJ Date Issued Issuing Agent Si afore it Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval TE 1 eptic tank, effluent filter and Cam. 33. dispersal cell must all be serviced / maintained as per management plan provided by plumber._ c e e and submit to the County only on of less than 8 1/2x 11 nches in size / as per applicable code /ordinances. �,/ft)9�_I to n&" C� vc -ism- rysl i� SBD -6398 (R. 01/07) Valid thru 01/09 . A7 i �' �' � � � � { 99`3 � 3x- 4 3x o Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County • Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information R Date Personal information you provide may be used for secondary purposes (Privacy Law, a. 15.04 (1) m)). Property RECEIVED tion Govt. Lot - 1/4 j 1/4 S T N R (o Property er's Mailing Address Lot # Blo # Subd. Name epO" NOV 0 8 2007 �J City Stat Zip Phone Number E] City ❑ Village ,Town Nearest Road ST. CROIX COUNTY ( ) P ❑ New Construction User Residential / Number of bedrooms Code derived design flow rate r6D GPD Replacement /❑ Public or commercial - Describe: Parent material T Flo Plain elevation if applicable ft. General comments and recommendations: "g� /�2,9 Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor > ,,L& in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. gont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 to A Boring # ❑ Boring pit Ground surface elev. 22" ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM ` in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 s • R 9 4 9 Efllue #1 = BOD > 30 < 220 and TSS >30 < 15 n = BOD < 30 and TSS < 30 Om CST Name ) ). Signature CST Number / L Address Date Evaluation Conducted Telephone Number 6p s' _ /` _ Property Owner Parcel ID # 8,�1 ;s'G Page L_ of Boring # ❑ Boring pit Ground surface elev. _.0 it. D L to limiting factor � in. Soil Application Rate Horizon Depth Dominant Color Redox Description -- Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz . 9:ont -IV. Sh. 'Eff#1 1 *0#2 7 a 9 9 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 •E02 F-1 Boring # ❑Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Efr#1 •Eff#2 Effluent #1 = BOD, > 30 < 220 mg1L and TSS >30 < 150 mgA- • Effluent #2 = BOD 5 30 mg/- and TSS 5 30 mg/t. The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R07 /00) i 44,, 4e !bf /ass i 4v/f � 993 t /f /,� -I 97y melee rte" POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page J_ of C2 FILE INFORMATI N SYSTEM SPECIFICATIONS Owner Septic Tank Capacity ga l ❑ NA Permit # / (�? Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Efflu nt Filter Model _ ❑ NA Number of Public Facility Units P�NA Parr Tank Capacity gal ❑ NA Estimated flow (average) gal /day Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer _E�NA Soil Application Rate gal /day /ft2 Pump Model ANA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit _;E�NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD <_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) NA Biochemical Oxygen Demand (BOD 530 mg /L In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L J (NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size % in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency . Inspect condition of tank ❑ month(s) s) At least once every: y ear(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (%) of tank volume ❑ NA Inspect dispersal cell ❑ month(s) s) At least once every: j F1 year(s) (Maximum 3 years) ❑ NA Clean effluent filter s" At least once every: month(s) ❑ NA 9 year(s) ��ect um ❑ month(s) n .� Pump, pump controls & alarm At least once every: ❑ year(s) 1KNA 'aterals and pressure test At least once every: ❑ month(s) fNA ❑ year(s) At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined .accumulation of sludge and scum in any tank equals one -third (% or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Page c:2_ of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cells) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring Power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal `bells: Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system, The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALL R POWTS MAINTAINER Name Name Phone _ -, Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ' Phone Phone This document was draf;cC - -_ := iance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. o N o 0 CA 0 C - u 0 tz M n I v o CD A I N A 3 I Q _ o cn -� w o m a o N I s c - 3 3 c o N Ao i..i "A. m o x Q N W O I N N Q M _ _ :z Ey N O p O CD O m co w n N w m M 3 3 <n ? w 1 N O- a "o Z1 D A U1 Q ;D O cD -D n y ro O O O Q m o ( ° m � ro o° m C) A� o 5 m I 3 rn o m m D r D C w l C d a A cn D CD fl. � I o N a rn CD ca' y a A C I W o o m n a c con con CD I� I p w °° m l N O Q y V Cnn � N I 0 : 6, CD (� -< (D (D o CO r N !�� CD oD o �• I y CD cm < y o c N N O CD a N cn cn cn N I cn N cn to O M 0 3 CD CD CD CD cn 0 N CD N zcoz I �o o zooz Q D a � N o -* _p D °- : CD CD cn N I rn= ° CD v%, (D N CD 05 I C CD CD I O CD ((D a I a CD CD -i Cl) =3 D :3 p Z m cn o (n n o A {,Zj I .. I M CD CD mCD 0 3 3 A z ° ° o (.0 y z I C I v I I =h m Q O< O co W Q I O Q O � R 52 _ m o: EA a N C N C c n O> - ON — 7 n 7 C O X OZ G I O O a Z63 :r o g o (D cn 0 CD m m 3 7, N N N o CD Co =3 S D 5' y °v A o o C>�_ 3 m I v O D M c w n N � I CD o CC y a N N 00 o 7 (n X x 3-o (n I o 67 N V r' a Q I A 02 o o b ro I (D ti o p I o p y C) •- I o ! V Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ��g�c 7ft• TOWNSHIP � SEC. �(� T 2+ - N -R _W ADDRESS i)'�� �6� �`�� ST. CROIX COUNTY, WISCONSIN SUBDIVISION r,,, , 1rM!"fc LOT . r 30 LOT SIZE yZ acg PLAN VIEW Distances and dimensions to meet requirements of II.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM } t X M dI INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: A 4Aquid Capacity: Number of rings used: Tank man a cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: ' Side Rear, Number of feet from nearest Road: Front 10 feet From nearest property line Front 1 0 Side,0 Rear, ® �3f feet Number of feet from: well building: 1Z/ (Include this information of the above plot plan)( 2 re i6rence dimensions to septick) SEE REVERSE.SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: ' Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of'feet from nearest property line: ' Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: K Trench: e � Width: Len$th: / /,� �i- Number of Lines : -_ Area Built: �8 Fill depth to top of pipe: , G Number of feet from nearest property line: Front, O Side, ® Rear, O Pt. Number of feet from well: 145`6 Number of feet from building: ZCa� (Include distances on plot plan). SEEPAGE PIT / Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK N /4 Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector • cm4r `7�ia yJ Dated: J Plumber on job: License Number: Mme$ #�.. r. 3/84:mj DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY &BUILDING LABOR &HUMAN RELATIONS DIVISION 1 BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: SE , NW 4 , Sec 36,T28-R19 �NVENTIONAL El ALTERATIVE (If assigned) Town of Troy Lot I'Holding Tank El Pressure ❑ Mound N'XMrz OF LD . ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Roger A. Swanson R Box 294, River Falls, WI sa3 / BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: 04_0 0 Name of Plumber: MP/MPRSW No.: C unty. &t 5&-u1'r_ r c(.dLJ-, Sanitary Permit Number: John P. Sykora III 3212 St. Croix 149049 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK IyL ELEV.: TANKSET ELEV: WARNING LABEL LOCKING COVER 3 PROVIDED PROVIDED: ES ❑ NO ❑ YES BEDDING: O DIA.: 1�Efd� MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY r WELL: BUILDING: AER NLE FRESH 1 f C ALARM: FEET FROM LINE lj ❑ YES 40 L S� E] YES NEAREST �� ell) �y r z r Tj DOSING CHAMBER: MANUFACTURER: MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: ER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET LINE: AIR INLET: PUMP ON AND OFF E:1 YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DI R: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO OF DISTR. PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID BED /TRENCH ( / TRENCHES: / MATERIAL: PI DEPTH: DIMENSIONS PIPE DISTR. PIPE M ERI L: NO I TR. PROPERTY WELL: BUILDING: VENT TO FRESH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR NUMBER OF BELOW I ES: AB OVER: ELEV. INLET ELEV. END: // �'vc' PI FS FEET FROM LINE: r I / AIR INLET: SL 5 Z 2 � ZF NEAREST O I MOUND SYSTE .S Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TR ED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SEEDED: MULCHED: CENTER: EDGES: ODDED: S ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: I GRAVEL DEPTH BEL PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE I MANIFOLD MATERIAL: NO. DISTR. DISTR. STRIBUTIO RIAL 8 MARKING: ELEV.: ELEV.: DIA.: El PIPES DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS [- ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: CQMI FEET FROM LINE: ❑YES ❑ NO DYES ❑ NO NEAREST —� c� t O �,.�e -✓ 9�y tz O Sketch System on fain in county file for audit. Reverse Side. sIGNAT RE: � 7 r E: SBD -6710 (R. 06/88) 7 01LHA SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couN STATE SANITARY PERMIT # –Attach complete plans (to the county copy only) for the system, on paper not less than chat if ❑ y ?d / 8'f x 11 inches in size. revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION P 6 , SL4.y sd 4 SP- % PAO Y., S - 1!c T Z8, N, R 14 E (o W PROPIMTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER , eev- w s CJ I ' , 15 z Z (7 15 S(r5 -9/ 9$ -P a.,r k II. TYPE OF BUILDING (Check one) CITY NEAREST ROAD ❑StateOWned '/ ❑VILLAGE: ❑ Public ®1 or 2 Fam. Dwelling -# of bedrooms PAR L TAX NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ ApVCondo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ RestauranVBar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION Coon Sao S Z43 .74 3 9G�8 "400 161 ' � VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks strutted _ Septic Tank or Holdin Tank n /Z b / N _f__ 11 Q 1 -1 Lift Pump Tank/Siphon Chamber El F VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) M /MPRSW Business Phone Number: I, 5 *� rte. Plumber's Addre (Street, City, State, Zip Cod . z bo )< 75 .91 Gc, i . �'�� 2-', IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sa 'tary Permit Fee (Includes Groundwater La ssue Issuing ant Signatur Sta Surcharge Fee) Approved ❑ Owner Given Initial �( /G?/ Adverse D t rmin tion X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS . 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE r 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) APPLICATION FOR SANITARY PERMIT 8TC -100 This application form is to be completed In full and signed by the ovnet(a) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended got tesale by ownst /contractot,lspec house), then a second form should be tetained and completed when the property is sold and submitted to this office with the appcoptlate deed recording. ------------------------------------------------------------------------------- Owner of ptopetty Cif — �r�J Z So Location of property SF 1/� __ 4d__. 1/4, Section ? 1,2 _: T -X:Ll _ Y Township „7 / Nalllnq address __�� 6 ri Address of site - 0 1 sebd ivis ion name ��i -'T��, T r� • Lot number ,,.....��.., . , . Previous owner of property Total size of parcel Date parcel was created Ate all cognacs and lot lines Identifiable? X Is this property being developed lot resale (*spec house)t_Yes _X i M o Volume 6�0 and Page Number ld^ as recorded with the Register of Deeds. -- - - - - - - - r --- INCLUDE WITH THIS APPLICATION TIIB FOLLOWINOt A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUMR AND PAOR mUMan, and the S EAL OF TH RROIBTRR OF DEEDS. In addition, a cattllled survey, If available, would be helpful so as to avoid delays of the reviewing process. If the deed deactiption references to a Ceitified survey Map, the Cattifled survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(Ye) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the ownetts) of the property described in this Information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. - A7 43 59 9 j and that I (We) presently own the proposed alto for the sewage disposal system (or i (we) have obtained an easement, to tun with the above described propettY, got the conpt uctlen of said system, syl and the same has been duly recorded In the Office eg th County R t of Deeds, as Document No. 9n ut of Ofentc Signature of Co -Owner (11 Applicable) Do of gnats a Date of Signature and 4M Agn A 10 t few me is St - Croix I "A' A l Tax MW Sik Lo t 30, Danate Park.Addition, Town of Troyv *x"Pt Its follows: Beginning at the S.W. corner of" i�_� lltid 30, thence north 10.00 feet along the w**t 1L*O of Said Lot 30; thence N 'OS 36 30" E- 127.22400.— $out 20-00 feet along the east line of said Lot �A 06 046 89 S3 W 126.8S feet along the south line of, said Lot 30 to the point of beginning. Oct to restrictive covenants of record. A _41*ri� will furnish abstract, and reel estate 'to, % -rated.as of July 1, 19sZ.) pro i CM1Vn Rasmussen 60 b"Weditameas MW the evaft beloftia& 406900sible in k* aiwO* sad free and etear of eacmWeac" WmMot as S*t forth an the attwjw d ocu m en t ; a a ll Md rights of way of record. htirsfand tssix". a 2 a, to t WMrto1F%J% r rp h 5 e o a s gn, kaj � 411* . day of July 00" (SEAL) PAN (SEAL) A. Rassuss AVIOUTICAT 14 ACKHOWLEDSU"i --AN o f STATE OF WISCONSIN Personally cam before we. the above aawW ­ 1030ft ITATE SM OF WISCONSIN A by 57%.%, Wi Sl QR VIARidraftd by GaY1_01r4 to me known to be th ME& Zia e person sconsin 54022 going instrument and �6 4 01c Ott 7 at acknowledged- Both Notary Public my Commission is d pw 9096citly ft"I be t"wd or Printed bolow tboir slanoturts. k8 7i;i STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER Pr �r.+�GTi�lS4 ROUTE /BOX NUMBER l�rso — c /3z $' FIRE NO. .1� CITY /STATE /C I e 1 ZIP Sy0s� .2 PROPERTY LOCATION: S, 1/4 NUJ 1/4, Section _�(o , T R .. L±_ W, Town of / Y'd y I/ , St. Croix County, Subdivision 1 l? j_e_ l� roc , Lot No. .30 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix ounty Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address r DEPARTNf ,, OF ' REPORT ON . SOIL BORINGS AND SAFETY &BUILDINGS IN D�ISTRY„ DIVISION LABOR AND PERCOLATION -TESTS `115) MADISON W 537 HUMAN RELATIONS 07 (1-163.09111) & Chapter 145.045) LOCATION: SEC ON: WNSHIP /MUNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION AME: S� 1 /* 0/4 - / T .2f N/R l7 E l0 TO 5 31 lea e r� COUNTY: OWNER BUYER'S AMEN A ADDRESS: Per 11 1 f �, o� 1 ,' P USE J DATES OBSERVAT O IS MADE NO. B DRMS.: COMM ER A DESCR PTIO STS: Residence ❑New ❑Replace RATING: S= Site suitable for system U- Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND ESSUR : SYSTE -IN -FILL OLDING TANK: RECOMMENDED SYSTEM:(optional) OS ❑� ❑$ ❑� ❑$ ❑� ❑$ ❑� ❑$ ❑� ..2p 2- If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROU NDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED — EST.TUG — HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- B 13- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PE RIOD 1 PERIOD PER INCH P. io Z Yz a P- P- P -. P- P- (PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9� ' f JA TN _ i 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 the location of the tests are correct to the best of my knowledge and belief. (NAME (print)- LOoq TESTS WERE COMPLETED ON: c�� � S fla� 2so.� ADDRESS: CERTIFICATION N MBER: HONE NUMBER optional): 9 i S aZ2 /S- 877 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — D DU E " O F REPORT ON SOIL BORINGS AND' S AFETY &BUILDINGS INDUSTRY, DIVISION LABOR P.O. BOX 7960 I HUMAN AND - RELATIONS PERCOLATION TESTS (115) MADISON WI 537W L OCATION: SEC TION: TOWNSHIP MUNICIPALITY: OT .: BLK. NO.: SUBDIVISION NAME: S . E 1 / 4 4)/ 3� /T Ji N/R /c/ E lord Ti Yo L��„ �� COUNTY: Ily ER'S BUYER'S NAME: MAILING ADDRESS: •.`� �tOi �( � G! P✓ /�� .J'Lt)lI /�St��� k ..5 /.Sum /,,2�� .�� ✓�� /�'�,' /.i �l/�.5�'Lr lS�� , •S �/� �' USE DATES OBSERVATIONS MADE �siiAL D S R TIFTC1 ESTS: ce L71New ❑Replace I JN r ' RATING: S- Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN- GROUN SYSTE - N -FILL HOLDING TA =RECOMMENDED SYSTEM:(optional) NS ❑u ❑S ❑� EI �U EIS ❑A CIS ❑ i % If Percolation Tests are NOT re DESIGN RATE: Q uired If any portion of the lot is in the I under s.H63.0915►ibl, indicate: lvlj Floodplain, indicate Floodplain elevation: 1 t PROFILE DESCRIPTIONS t BORING TOTAL DEPTH TO ROUNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH i NUMBER DEPTH IN, ELEVATION OBSERVED EST, HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i B- 89 491of No „e > 8� �� "et7S /7 ;b.,1 s,i .�o" _b,,�, ,�,� - s, B- d0 91 /kwe > su /y s.l , , .., / � r .•� - sax / ro � s , ' ~ B- 1900 � ie > �'-�' /y h?X7SS• 1, B- q 9A AO B .fi /off y dvie 7_s,s, /, I 6,,, B- � �QX �� // I Ai le > Y,s3 /7 ' Cd l 55./ `.l PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. I D PER INCH P. p. .2 / ' P- P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION ,z 3,, t / /, t7 2.. -- AIM tN t ,. 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistretive Code, and that the data recorded and the location of the tests are correct to the best of m V knowledge and belief, NAME (pri : TESTS WER CQMPLETED ON ADDR ES ` 7,f CERTIFI /iTI. NUMBER: HONE NU E optiorlal ): �X 14 , 11/ S [ 5.•• _5 /!/ to / t ;;�� CST SIGNATI)RE: DISTRIBUTION: Original -Local Authority, 2nd page- Bureau of Plumbing, 3rd page - Property Owner, 4th page-Soil Tester. DILHR- SBD-6395 (N. 031811 V l N t �lu Alt 96 s � •c 1 � t o t IDL ; w • S rL �' e_c.. Z (o r T Z $ 1V F.'� 9 W – 7 - 61A k-%. (56 '7 5 7� C041.%( Ca MPpS�►�2�2 IN df C �~ ��-Jr 1..F ,J A - � %4 p osd - �-�� O = R.•P. / s �:e_ ~ / L S' K cs' du -.►�ti. c � � . �1 N Iab a i c *-e -s D�' lt.a 112-- – ct 1 srLt ,r �I �+ � � , \ n ■ ■ � n 0 ) g � e s w E z o 2' ® w 2 7 §" o C-0 } i z n a ' ¥ CD ; E ( § \ a — % j d J a& 2 2 a m o to * E § z > ■ E I co CD \ �° 8\ CD a a CL CD / k co 9! § 0 c ~ ~ \ 2 T -0 -0 ; ! & TWA. z o 0 0 ,! C r 2� § 2 7 ■■ ■f� , to 0 R CD & 2 � \ > ( ƒ \ o § % / 7 CD �. ;o 2 @ . { \ m / CD / . \ CO) / k k CL 0 m / z § A z 2 E&z §E ^ k _ Co=la CD 00 § c - cL0 E���c � . j 0 C . b z } 72Ei 3c� /Q� ( m28 ■ SD 0- . 7 �§( ƒ DC ] ; k ow ■ 2 ¥' �e21 . &(D . / 0 k( § $ EQ a 0 » . < % \ /? kE �2 � I - I Parcel #: 040 - 1183 -50 -000 11/08/2005 04:59 PM PAGE 1 OF 1 Alt. Parcel M 36.28.19.746 040 - TOWN OF TROY Current I[X 1 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-owner ROGER A SWANSON 0 - SWANSON, ROGER A 962 BRAVE DR SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): ` = Primary Type Dist # Description * 54 RIVERSIDE DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.435 Plat: 03 /58- DANATE PARK SEC 36 T28N R19W LOT 30 DANATE PARK Block/Condo Bldg: LOT 30 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 36- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 903/168 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.435 38,000 152,000 190,000 NO Totals for 2005: General Property 0.435 38,000 152,000 190,000 Woodland 0.000 0 0 Totals for 2004: General Property 0.435 38,000 152,000 190,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 EPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING M)tDISON, WI 53707 IX CONVENTIONAL ❑ ALTERNATIVE State Plan I.D. Number: (11 assigned) El Holding Tank ❑ In- Ground Pressure ❑ Mound NAP OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: R Uhf LS BENCH MAV (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. Ta n R 7r Name of Plumhe, MP /MPRSW No.. Counry. Sanitary Permit Number: �-, 10, 8 l6 SEPTIC TANK /HO DING TA MANUFA ,STURER. LIQUID CAPACITY. TAN INLET TA. 1�71F,T VWARNING LABEL LOCKI COVER 'r j "1w ED: PROVIDED'. l 9 r0 (� El NO ❑YES ONO BEDDING: VENT DIA.: VENT MATL HIGH WATER ROAD: PROP RTY WELL: BOILUING: VENT TO FRESH /.� ALARM LIIE JAIRINLET. X YES ONO ❑YES ONO OSING CHAMBER: MANUFACTURER BE DUING. LIQ D CA A ITV J PUMP MODEL PUMP /SIPHON MANUFACTURER WARNI LABEL LOCKING COVER PRO ED.. PROVI ED: ❑YES'"/ NO YES O YES ❑NO GALLONS PER CYCLE: ,* PUMP AND CONTROLS OPERATIONAL:;' PR PERT BUILDING VENT TO FRESH (DIFFERENCE BETWEE ', L E AIR INLET. PUMP ON AND OFF) DYES ONO SOIL ABSORPTION SY E eck the soil oisture at the depth of plowing L H ON �D ER TER7A ND MARKING or excavation. (lf sot an b (led into a wi ,construction shall cease until the soil is dry enough to continue.)A _�.. _. CONVENTIONAL SYSTEM: $" `'sd'. WIDTH LENGTH I ND OF DISTR PIPE SPACING. COVER INSIDE OIA. LIQUID T11,1� B -�' MATERIAL DEPTH'. L -- ' FILL DEPTH UISTH IPF DISTR.PIPE DISTR. PIPE MATERIAL NO. 3 PR PERTV WELL BUILDING: VENT TO FRESH BELOW P AB COVER EI Ev. INLF I ELEV END PIPES t x LINE AIR INLET. '. g', ?', t� MOUND SYSTEM: 1 C -S Mound site plowed perpendicular tp slope he the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: l u d systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- f me e criteria for medium sand. TIONS MEASURED. ❑ YES SOIL COVER TEXTURE 7 PERMANENT MARKERS OBSERVATION WELLS F f f' DYES 1:1 NO DYES ONO DEPTH OVER THENCH BED E OVER H NCH.BED �EPTH QETOPSOIL SODDED SEEDED MULCHED CENT EH EDG 4 ❑YES ONO ❑YES ❑N O ❑YES ONO PRESSURIZED DISTRIBUTIONS STEM �;;, !a WIDTH LENGTH NO LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER T, T NCH MANIFOLD PUM M IFOL DISTR. PIPE MANIFOLD MATERIAL NO. DISTR. GISTR. PIPE DISTRIBUTION PIPE MATERIAL &MARKING ELEV- fL - D A. ELEV. PIPES. DIA.: HOLE SIZE OLE CING ILL D CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ONO ❑Y ES ONO COMMEN f T + PERMANENT MARK 5: OBSERVATION WELLS: ' _' T. PROPERTY WELL: BUILDING'. _T LINE: c, DYES ❑NO ❑YES El NO to Sketch System on eta' ounty le for audit. Reverse Side. SIGNATURES. TLE. DILHR SBD 6710 (R. 01/82) DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LAaOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 I j Attach plans for the system on paper not less than 8Yz x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Prporty Owner : Mailing Address: c.�,4 So �( ,%.y SOS (Jis , Property Location: d q City, Village or wnship: Coun y: s '/a lu /T f � NCR /l E (or ! � 4 1� . (wal )I.- Lot Number: Blk No.: Subdivision Name: N rest Roa& Lake or Land rk: State Plan I.D. Number: h / p (If assigned) to TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedr El or 2 Family * State Approval Required. ;rx 4w TOTAL NUMBCR PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TAN S CONCRETE PLACE NEW MENT (Specify) SEPTIC TANK CAPACITY Ig 0 HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM U S T At C - T v 9 — � C.- PERCOLATION RATE ABSORPTION AREA - q (Minutes per inch): PROPOSED (Square feet): 9-New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): rivate ❑Joint ❑Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Nam f Plumber• f / Signet ur M No.: Pho a Number: Plumber's Add ass: N of Designer: 4 �r1. r��t / �,� COUNTY /DEPARTMENT USE ONLY S!ppature of Issuing A t: I k a: Daate: p ❑ APPROVED Sanitary Permit Number: too-o o f �^ O ❑ .DISAPPROVED g Reason for Disapproval: I Alternate course(s) of Action Available: I I Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. y i DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR SBD -6398 (R.07/81) Ii EPARTMENT OF APPLICATION _ SAFETY & B UILDINGS INDUSTRY, FOR SANITARY DIVISION LAQOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8 %.x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physicar characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy.must be included. Prope ty Owner: Mailing Address: A✓ 4, It A2 w fa //s 4-4 C7 Va a z Property Location: City, Village o ownshi : County: $ '/a Ao iu %S /T B N/R / 4' E (or Lot Number: Blk No.: Subdivision Name: Neares o Lake or Landmark: State Plan I.D. Number: Q (If assigned) h� W 10 f� TYPE OF BUILDING Number of ❑ Public ❑ Variance ❑ Other (specify) Bedrooms: ® 1 or 2 Family * State Approval Required. TOTAL NUMBER PREFAB POURED -IN STEEL FIB NEW REPLACE- OTHER RGLASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY p p HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM vs yc PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 9 Seepage Bed ❑ Seepage Pit 2 G 01 1 Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: V1.1 ISig t e: MP /MPRSW No.: I Phone Number: Plumb s Address- ame of Designer: QSSt � G"�iJ'ri /r n t COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: efe� ( D]ate: Q El APPROVED Sanitary Permit Number: 4 a/so� &mLvJ � IDCJ. © D �O7L- ❑ DISAPP ROVED 0 / Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or lumber requires a Sanitary Permit Transf 9 P, 9 p q Y r (67 -T) to be submitted to the county prior to in- stallation. Failure to cdmply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod- Plumber DILHR -SBD -6398 (R.07/81) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LAQOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS LOCATION: SECTION: TOWNSHIP /MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISIO NAME - S� 1 1#'14 3!0 /T 21 N /R /9 E (or 7ro 3a Donate Pb.-k COUNTY: OW ER'S BUYER'S NAME: AILING ADDRESS: i l ;D r A. USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: II STS: Residence T (New ❑Replace L �u /y / 2 1 19f2 y 13 `?f7 7 —7 J RATING: S= Site suitable for system U= Site unsuitable for system TAN]RECOMMENDED CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: S STEM -IN -FILL OLDING SYSTEM:(optional) ©S DU DS ❑U ]S DU DS DU see �e Oo o Z If Percolation Tests are NOT red re ui DESIGN RATE: SYSTE 4 / /'? �� I If any portion of the lot is in the under s.H63.09(5)(b), indicate: 2 ryG 9 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROU NDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIG HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) D B- l $0 /a `�' /1/ �8 13 "St 7�, X1, 17 " hrn s,/ 3d"= i�.zj, B- 2 �8 �� / Ott e > 7-V s,/ Ap "hr s ;/ ax " 0,97 ',w.+/, ra ✓�1 B-3 o08 da, e > - ��/ p Bit'7SS.'/ l9 "bmS.� �� �`satd a7 "Srr.►�r ra ✓� B- 9A /0/ 'J( /VdA e > 9A 11 ��' * s ; J" - 'li rA s./ _w "sand a2g B- S q� /0 / � � �� /I�o/!e > Q� 1414, `�E3rC TSs:/ / " &f) S _? -0 /7' 73 s ;/ /� • '/Jrn S.'/ �/ X 27'' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- 0 S v )' P- ,2 O J �Z- s YL P_ 3 Z 66 P-. P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION M .. . ,.. s r -r — F�� �.. f ._. _ - I m M _. #.. I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (prin : TESTS WERE COMPLETED ON: Pf A 44/ /3 lioz_ ADDRESS: CERTIF !n TI NUMBER: PHONE NUMBER optional): 7/s is R�? S yvev J/� WAS consr .sya zz 0la �v has- 9i�� CST SIG T RE: i DISTRIBUTION: Original -Local Authority, 2nd page- Bureau of Plumbing, 3rd page - Property Owner, 4th page-Soil 4aster. OILHR -SBD -6395 (N. 03/81) 1 � _ 1 � � a I .. ' t' -.. .... _ ` - _. t �_ A .. , ;,: ._ . P � A^'` r ` \ R - _ �; c .. �" .� �. . � ` � _. . � A _ ._:� .� , -. � - - <: � �- _ „, � .�..— .s' . _� ..;, __ _ �.y ..._ -.. _ •. Y � � .. - J \ ,, _. ,:. �� _ i,, I q. L4 Q ° / a Q C �" M 5 SIZ µ J Imo. A4 0 v t �` �"�• QJ o Ql d � 1A 40 ? '�" LL, b Y f 1x �R i g 3' a A J xi _ { f � 4 x MW design M -912 1CONOMY IN - � �6bSACJCNn Kf7 f41 ,IIY beon.00m �-in �.zXt14?' ,fx,f, SPLIT -ENTRY PLAN The bi -level conce t of rental, units is popular. This is understandable, — for, it is a fine way to gain a maximum amount of Iivable area in _ - – the basic floor plan. A common o vestibule leads to identical erorsaca sronace CL apartments, each of which have 9E6X°OO rs 4 4'r iAa "p two bedrooms; stocked ,washer- drygr and a noticeably small hallway. r .. G 1 c.N hgGE RRGE CL nr•�xsr6 The attached garages with _L _ extra storage room w'ili prove to be a 'pleasing feature. 6 rsoun D - Ploo.;R -- 1,008 square feet ' 19,152 cubic feet (not incl. garage) ; f J to i i -7- r S ' r , vA - r 9 ,r .r N99' /T'W 1727:,5b /70.00 4 • x cso Z c 'A. 9 2 0 a h 0 ae. o Z c �°,• I fi m o all O 8 A 15 1:4..•, x a, C% 10 o ' ' � s � o E'��s•oo' / x o.00 �.►. 9p /80.00 s 90 13 T Q'1. h � 1 0. f a r r 0 a W •� g %,. 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G. _ 1660.,2 f f N. ci n d 4.2.7 *+ W "7 o� °eo.o�,;. 9 l2c.bs �. ,/�_t_/ of S.corncr o�Saa.3�2►.1q_ C J •99'S3'E 3/3.50 o GG f+ pvblIc QcG.ctss o - - o fo river `PUBLIC ROAD w J ` Walton K. ahnson - �• Director, P(annin 'vi �0 14 Lor P p / / AT Department of Re source Dovetopment d / . -- NE 1/4 S N W 1/4 o f Sec ��• c y TOWN OF TROY, ST CRoIX e WISCON / ° 0 LOCAT /ON /y AP N J �4`/ Sec. 36-28-/9 Surveyors Affr'dovi -/•• S +a+a of Wisconsin 2s,e DANATE Cour7f y of P/erce f air7dicatos PARK e qcca I, James R. Grubb surv l "dta#". iron All 4i3 fonaes ' ip 3o " onq, ldn f , divided, 4nd �'Y/aPAed ds / D , P,t 2 ft q h s and aui yhe N. W aq ua/- fr a qhd - fhc °' • 36, T2 8 N., R. /9 W. 4Yndic-gfes )7epr -ez4 0.0/ of then de, scr -ibed qs fol /oa, 7- dia»7.iro'n afoot NO7-fh and 42.70 fee-/-_ we. ,3 ppe> 30 " /on Sazc 36 - 28 -1 + e /3 w ar ffP Y 9; h nca Due; N P Corpora+& L; ,*$ It a Cl/s*GnGe O /72 f fo -------- - - - - -- -. .- ... - - - -- -- Perco /q +ion and ' Kir7r7iCki17n;C- tQiv2r - ; then v G/f " of R/ er Soil -fast /?o /e ing - 017agnO'er /irks: IV /3 N shoa„ +hva: distance of 6,50.00 fewaf, Nr, •p x sr /S'w a distance of / /0.00 f �•l` t hartolea¢loq Soil fe /V 42'06 p d is f G°RNEIe He /s lsor,w) river N 89'17' W q disc r7e¢ Bunch Mark Top of "fc7nce. of 5 /3.00 fee* +h errc' y : t'henc-e• Due, S a d/s o f. o 2'x 30" /rorr pips let 5. of 30.00 fee. ,a ncm Dui. Gorr7sr. E/ay. 882.3 � th S 89 S 3'E 4 d /'s +ante of 313. r�s o /079 c7 // lands lying ba #w c`n sc >0 said ri var. I certify +hat I r l3i'o�� r +he c1%eecf1'0r7 of 1/e -rnon L. Ra. • ^ `0 93'x/ ens o-F said /and ; -thQ4 suc 1 s., al/ exterior- boundaries va I a y '.r•. o . pp / ' +lhere-o-f Mad +ha f I GhgP+&-r 236 of +he Wisconsi s s Y% er7iior7s of .the Toeun of 7 /, a. w f�s'w' some.. y Ya�rlr' el o s 09/ t Subscr ibed and sworn +o bcfor f AOe eet y - this 27 th day of July, 1961 ScQ /c iri ` No +ar Publ Pierce Coup +y, \ y �'• This i175+run7enf Wqa �/ drafted b t/aara7aZS R• Grv6h V Wis. Re No. 5 -722 , du /y' Owners' Gdrfificq-Fe SfQ of Wr's consir7 s s \ C1 Counf y of Pie) �. All lots abo h ereon As owners, we ha.raby carfify \(� •fo be served by peiva4e: this plQt to bat surveyed, divide wc►'far d adcuaga ays faLr,7s- o r7 +his P/,Q- We, a /so CC)- +tf \ Resolution: or s. 236. 12 - to be subrni+fe C- +ior7: D, +o Plg r, nninq D; �,• "Resolved, fha-l' the p/af of Danq+e Park J Z in +17c Town of 7roy,Verr7on L. RQs►rlus- OPMe-n+; SfQ +e Soc7ed of He �kr sav7 and Caro /yn A. RQ3n?Vssan, owr7ers, be gr7d Town Boded of - the Tow Qppeovdd by fhe C/f Gov l." Wi+ a c h ss + 4�asi a or � .K�.✓ h and Qn sea/ y� I hareby ces -4ify fhq+ fhe fo dyoi is o C�opy of W /frldssas y� q )-¢solution Qdop +ed by +ha C-I*y Go&nc;l of +he i Cify of Ri vcr Falls q+ a me&Y in ha n Q• r -,.* C /azrk y Persoi7al/y Came before #no. 4 a.soNvcd, thQ+ +ha- p1Q+ of 77gr7q+e Park in +ha- Town ed Ve On L- F{asmussan an 'oy,1VQt - non L. RQ.S?nussa►� qn Carolyn 09. Rgsen +h e p2rsor7s who CxXacu*zcif 's• bPat., QpPr by +he Town Boq d." / yea 'f'l�¢ sarr7e. Town G1?girrnaan y c.�r +tfy fl•7a+ - Ma foragoing is a r-opyy of q eazsol- Notary Public, P/ eras Co. Vl Q Opjo by -f a Town Board of +ha 0 n o Troy , :a + /rf'�9 held o►7,a �,� 196/ The First Nq +ior7a/ Ba►7k of •Town Clark gan ar7d e•Xis+.tn9 ones./ ,� Elsa Curve Do- S+-q ofA,•►7.1 rr/or-f'yay¢a o I9il 079.0 5& fo the Survd ,x ir7 di v h, 9h 8'76.0 Curve Chord Br Chord L. Raa'ius Card 4 y J, /ow' Q7L.p /Qhd described on +h is pla q N53'6 95.03 50.00 143'44' Gar +, fie q f y 0 f VQrr7or7 L. R 8 N 3 * *T V 54.00 / /000 28'24' 0wnazrs. C N26'37E 61.36 32'24' IN WITNESS WHEREOF the \ \\ D N69'5_1'E /00.00 54'04' these presen*s to be si9#7e,� __ E NG8'4l'W 54.82 28'52 s F N 64'l 7'E 14S.6B BZ'Sfo '9''jed b y Doris L grson i ,�-s ca G N56'27E 28.26 40.00 1 /'Zf' Cour7�l y, W ;sGO »stn, Arid /ys c H N 9' 15 S6.57 90 .00' +his z 7;' y 0 U u l y, 19 � I N60 E 72.92 !3/'26" -Tn *he presence^ of.- i "• �� -. � �� �� :fi t►, zrn 7w I7.� L4 fan � � �_ <'+t•�'' , tea\ u�'. p, i Parcel #: 040- 1183 -50 -000 03/01/2005 04:33 PM PAGE 1 OF 1 Alt. Parcel #: 36.28.19.746 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * ROGER A SWANSON SWANSON, ROGER A 962 BRAVE DR SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 54 RIVERSIDE DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.435 Plat: 1891 - DANATE PARK SEC 36 T28N R W LOT 30 DANATE PARK Block/Condo Bldg: LOT 30 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 36- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 903/168 2004 SUMMARY Bill M Fair Market Value: Assessed with: 27550 189,600 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.435 38,000 152,000 190,000 NO Totals for 2004: General Property 0.435 38,000 152,000 190,000 Woodland 0.000 0 0 Totals for 2003: General Property 0.435 40,000 140,600 180,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 IN TM,I`NT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, G DIVISION BOX LABOR HUMAN A ND MADISON PERCOLATION TESTS (115) MADISON WI 79 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP /MUNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME: 5,c ' /*Q/ -3lv /T_9fN 1Rl9 E (o T 1'as e )Of rk COUNTY: OWNE /BUYER'S NAME: AILING ADDRESS: C af USE DATES OBSERVAT ONS MADE NO,B DRMS,: COMMERCIAL DESCRIPTION: ROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ❑New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND- PRESSU E: SYSTEM -IN-FILOLDING TANK: RECOMMENDED SYSTEM: (optional) �S ❑U OS ❑� DS ❑U ❑S L H ❑S ❑U z If Percolation Tests are NOT required DESIGN RATE: If an y portion of the tested area is in the under s.H63.09(5)(b), indicate: OW11 I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED I EST. HIGHE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- B- B- B- B- I PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PE 1 PERIOD 2 PERIOD PER INCH P- )Q yz j'z _? a 12 P- C P- a P -_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION F j(i tk ' 7 7 rt t i , � I E f f t i e t F i i { � t � t { � ( ( i All i 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Ko clll X S u1�rc S�r. ADDRESS: �n) CERTIFICATION N MBER: PHONE NUMBER (optional): CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — I INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; B. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6, PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A sr; sheet may be used it desired; S - Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 0 - Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N_A. in the appropriate box; 11 . Sif.1n the form and [)lace your cUrrent address and your certification number; 12- Male legible copies and distritrme as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL_ AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10 ") BR - Bedrock cob - Cobble (3 - 10 ") SS - Sandstone gr - Gravel (under 3 ") LS Limestone * S - Sand HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate rued s Medium Sand W -- Well I's - Fine Sand R;dq - Buildincl Is - Loamy Sand > - Greater Than sl Sandy Loam <- Less Than 'I -.- Loam Bn - Brown sil - Silt Loarn BI - Black si - Sitt G - Gray c - Clay Loam Y - Yellow scl -- Sandy Clay Loarn R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay wl - with sic - Silty Clay fff - few, fine, faint c -_ Clay cc - common, coarse pt: -- Peat min - Many, medium m -- MUCk d - distinct p - prominent HWL - High water level, Six general soil textures surface, vvater for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: This suit test feport is 'the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to 'oe n k issuance. A complete at of plans for the private anra €le systenv and a permit application must be submitted to the approprt <ata local autl,ority in order to obtain a pe.rrnit, The permit must be obtained and posted plior'to ? }� Jtvrrt, of anv cc, r;straction. j D ATMENT OF R EPORT ON SOIL BORINGS AND S AFETY &BUILDINGS IN I INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS P. °. B OX 7705 ( HUMAN RELATIONS 1 J MADISON, WI 53707 L OCATION: SECTION: TOWNSHIP /MUNICIPALITY: OT O.: BLK. NO.: SUBDIVISIOI)J NAME:, SE 1 /n0/ 36, /T )i N /RJ9 E io4W T'ry v 1? I1+ 4,. r COUNTY: OI/1� ER'S BUYER'S NAME: 'MAILING ADDRESS: ,J C tO i JC G(Pr' l Gt�C'lllspn /�v?C /w? �l JJC� ✓ Pr //r ei 110 Sf 1Sa -� �" ��� �' .' USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: Residence rv� r S: R ESTS: i L New ❑Replace J / J u ly RATING: S= Site suitable for system U= Site unsuitable for system Y CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- K: R ME ED SYSTEM: N -FILL OLDING TANECOMND SYST ©sou osau osou osnu asou se,? r-e ,..j If Percolation Tests are NOT required DESIGN RATE: S / If any portion of the lot is in the F. under s.H63.09(5)(b), indicate: ,t �v�j Floodplain, indicate Floodplain e levation: PROFILE DESCRIPTIONS µ BORING TOTAL P H TO ROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH I NUMBER DEPTH IN, ELEVATION OBS EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 800 /49 0 B- Alowe 13 et 7 / .... ,6,,1 3 .r -�i r , r u'.�i i � ro�✓G B- 2 �8 /v�J.re sJ /y s./ .� b s'f 1 i' sa :�c�rrjl X� ./I r.:. ,f rn i I j r� / B - `J S� L/' �y ' /Y ilk `! /y /� f�.. �1�. " Si/r� ✓J7 /}ri(!I °jJ:.o.? (� ® AA r [ B - ! 9.- A4/ �.: , 1 V I A �lv I.S Si / + /,f L/rrl3/, .J <J - ..S a 1iL/, ..'l� ,- %.1C1 h ` 7 ►. ' ►�;� B 7 �O� / 7 Ill,we 75 Si/ f 0��1 i/ J� / SJ. /�'�[ w� I• +/! i '' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PEHIOD2 PE R10i571 - PER INCH P. P__ P_ PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION �� r s0 re l ilk J !/5 4 3, INI TN le. &Itf . �._. m.. 1 I,'the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (pri C TESTS WERE COMPLETED ON: ADDRES ? J j CERTIFI 9TI NUMBER: PHONE NUMBER optional): {I/l.S rC >ilf J1I/ 2 2 _ CST SIGNATURE: J DISTRIBUTION: Original -Local Authority, 2nd page - Bureau of Plumbing, 3rd page - Property Owner, 4th page -Soil Tester. DILHR -SBD -6395 (N. 03/81) 00"• ' _ v � Y I R j 1 4.1 --.Z Q YY t t - , 1 � G� *Jq f 9 I M •a 4 Z LA 40 d � a • •