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040-1204-10-000
r - Wiscofhsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix I Safety and Building Division INSPECTION REPORT Sanitary Permit No: 515126 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: Marr, Richard & Sharon Troy, Town of 040 - 1204 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No: 25.28.20.947 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER r CAPACITY STATION BS HI FS ELEV. Septic pJ Benchmark �• � t a,1:' �e,k,5 1600 J /6), 1.8-11 Alt. BM r;+ % zoo ( L, 332 ik5 0 A - Z '77,75 Aes2aien Bldg. Sewer �•t Pa 1 k. S , a Holding V St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 67. /� ��o • S TANK TO -` P /L WELL BLDG. Vent to Air Intake ROAD 94-Inlet 5 •�7 /V o ��•— 51 64 W �s 241 ,jr•r� Dt Bottom Z i /a162- 66 / - 7 �z Zb 1 6414- 5 3Z. ? ( a -33 Dosing Header /Man. �. Z 75. Aeration Dist. Pipe c � 3. Holding Bot. System + �/_ 47• bK Final Grade `P PUMP /SIPHON INFORMATION Z •75 `��• 1 Manufacturer Demand St Cover 9 $ + c Z. GPM 4 e ak. 210 L G 7 Model Numb TDH Lift Friction Loss Syste TD H Ft Value. o��- ��..� 5 ,5 � 5` • l Forcemain Length Dia. Dist. to Well Vg 6)4- 5Z[716 g 13 SOIL ABSORPTION SYSTEM BED /TRENCH Width Lengthy No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS C �^j 7� � � •� SETBACK SYSTEM TO J P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of System- HAMBER OR m + UNIT 7Z I Model Number: (9,) ; / DISTRIBUTION SYSTEM �tJ -L � /q } 1 �- = `yc C�s...f Header /Manifold, / Distribution x Hole Size x Hole Spacing Vent to it In ke Pipe(s) \ \ \ Lengt Dia_ Length Dia \ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only C Depth Over / Depth Over xx Depth of xx Seeded /Sodded r Mulch Bed/Trench Center / I ` Bed/Trench Edges Topsoil Yes [] No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 181 Delander Drive River Falls, WI 54 (SE 1/4 NE 1/4 25 T28N / R20W) Plainview Acres Lot 1 Parcel No: 25.28.20.947 1.) Alt BM Description = � `� \ G aJw, 41 ( Sc.fe,J S 2.) Bldg sewer length = - amount of cover = J Plan revision Required. ❑ Yes No �l 7 �� - f -- _ � _�__ 3 � 1� Use other side for additional information. �_ �. — � _ __ _ I ' SBD -6710 (R.3/97) Date Ins epcto, Signatur Cart. No. commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix i s c Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce I State Transaction Number Sanitary Permit Application Na 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: Applic 'on forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal inform 'o provide may be used for secondary purp oses in accordance with the Privacy Law, s. 15.04 I 1 V m , t I. Application Information - Please Print All r LJ Same Property Owner's Name Parcel # 040 - 1204 -10 -000 Richard & Sharon Marr t 7 Property Owner's Mailing Address Property Location 181 Delander Dr. $ CC-()IX cOUN Govt. Lot City, State Zip Code one Number NE / <,NE -/<, Section 25 River Falls, WI 54022 (715) 425 -0262 (circle one) II. Type of Building (check all that apply) Lot # T 28 N; R 20 W ® s 4 1 or Z Family Dwelling - Number of Bedroo Subdivision Name 1 Plat of Plainview Acres Block # ❑ Public /Commercial - Describe Use City of Na ❑ State Owned — Describe Use CSM Number ❑ Village of Na ® Town of Troy III. Type of Permit: (Ch eMy -one box an line A. Complete line B if applicable) ` New System Replacement Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) System B. ❑ Permit ❑ Permit Revision ❑ Change of ❑ Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner 7 3 Expiration 0 l U IV. Type of POWTS System/C omponent/Device: C heck all that appl ® Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretre ent Device (explai Hoot H - 600 ou- V. Dispersal/Treatment Area Information: J Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sl) Dispersal Area Proposed (cf) System Elevation 600.00 sq. ft. 0.70 gpd/sf 857.15 sq. ft. 857.40 sq. ft. �,/ 92.50 VI. Tank Info Capacity in Total # of Manufacturer w Gallons Gallons Units o w U v a w E New Tanks Existing Tanks O N a 0. U Septic or Holding Tank 261 1000 1261 2 Weeks/Wieser Dosing Chamber ,, /�{ �1C� VII. Responsibility Statement- I, the un rsigned, a sume responsibil' or nstallation of the POWTS sho on the attached plans. Plumber's Name (Print) Plum is Si MP/MPRS Number Business Phone Number James K. Thompson 5---- 30021 (715) 248 - 7767 Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, WI 54020 -5413 VI . County /De artment Use Onl Approved _ Disapproved Permit Fee Date Issued Issuing Age t Signature Owner Given Reason for Denial $ IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be Serviced / maintained as per management plan provided by plumber. �(� • _ y �� '�� , t� i 7 `L 2. All setback reQuirements m as per applicable for the system and submit to the County only o paler not less than 8 1/2 x 11 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 AeiGhCUci - o,-) /Y(u.�P�of D.t /a.., c 4,, Z�-. ,�dL, -Fads oil. sW,2 Ld�/ ��Q�OfQ�Qin vj � AC /C� b i1 Ey��Eyy sec. 25 - 7 26 1( a Cow o izos- /o. -oz ola Ea'i S Einq cJe !/ c i U d.� 7"a/'aFs.T." 0 p Q cd„c�� s,ae J • y 6.cd IP GSi d��CL wie' Q i paut' oFS,�✓�n�. 35u 98.x' � � /�ra�std (r.Je2t�s GmG.zG /ya0. •.' OA- 5.2 `eFF /u�t 1 lecll.Tli�ec(. 5 c� , -Fgce Claw = 9Wzs.' 3 X 58 "Y /S/ Q-S' .t Cha., 44ru,04✓ n041 99 So' 83 6 Sticd LECpPY �L�Gnol2� c4 Lam/ P /�t � ofG /ct.i vi � �cleS � Els�rlEly Sec. 2 S 77 2B�( 1P 20�J T. o�7 y , S . C/ziK Cm., mil. R cow gf a io -cam • e.da /cca6c,,�o•� ♦ EX,Sii�q� trade elegy bJe l/ C ' 0 Ge„cc Side •JQ EX, 91q, Ab ' y bcdicr�n, tae It lo�iC' �dtarn �� le4 CcJ,�Se. i i I Or o �std UJtpil�.s G.�C.,tG /� !3( •' 'l 6(,0 lam- -A/ bl Lot' 90. SDI ConfSKr f�opasald ..•spusa /Cc.�l.� 54�r�,cc e %µ = 9�2s r� /fi a c%a,. bwu 9�0 B3 ,' 6 i e- Soil Absorption Svstem Cross Section 997" mss' ft 98 ,7.s- 99. zs' ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 93 20 ft f- Leaching --► Chamber System Elevation .2. 63 ft �.cb ft �.� ft Soil Absorption System Plan View ft 2-83 ft &. Do ft Leaching Trench 1 Chambers 4" Dia, Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications Manufacturer And Modet /mac. EISA Rating ao.D sq ft per chamber Soil Application Rate 0.7 gpd /sq ft _ !lam_ gpd Design Flow- O.7 Soil Application Rate + Zo.0 EISA = 4a.66 Chambers 3 rows of chambers each. Page of 2178 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page t of 3 Division of Safety and Buildings in accordance with A.C.E. Soil 8 Site Evaluations Comm , mss, de Attach complete site plan on paper not less than 8%x 11 inches in s' P nr County St. Croix include, but not limited to: vertical and horizontal reference point (B n an percent slope, scale or dimensions, north arrow, and location and di t rest road. Parcel I.D. 0- 1204 -10 -000 Please print all information. i� (� Reviewed y Dat s� Personal information you provide may be used for seco 15"I M 9 taut, s. 15.04 (1) (m)). Property Owner Property Location Richard & Sharon Marr AUG 2 4 2009 Govt. Lot NE 19 NE 1 S 25 T 28 NR 20 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 181 Delander Dr ST CR0 11 ON G OFF L 1 Plainview Acres City State Zip Code Phone Number _j City J Village Vj Town Nearest Road River Falls WI 54022 (715) 425 -0262 Troy j Delander Dr. I New Construction Use: _f✓ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD ✓_j Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for re 92. e7t conventional POWTS using 0.7 gpd /sq.ft. loading rate. Recommended system elevation 50'. Boring # I Boring 1+ Pit Ground Surface elev. 98.39 ft. Depth to limiting factor 1 1 5 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD& in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 1 0 -9 10yr3 /2 none sil 2fsbk mvfr aw 2f,1 m 0.6 0.8 2 9 -20 10yr414 none sit 2fsbk mvfr gw 1fm 0.6 0.8 3 20 -26 10yr4/4 none gr sl 2msbk mfr cw lvf,f 0.6 1.0 4 26 -36 7.5yr4/6 none Is 0 sg ml cw - 0 1.6 5 36-76 10yr4/6 none s 0 sg ml gs - 0.7 1.6 6 76 -115 10yr5 /4 none s 0 sg dl - - 0.7 1.6 2] Boring # J Boring Pit Ground Surface elev. 99.08 ft. Depth to limiting factor >121" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 - Eff#2 1 0 -15 10yr2/1 none sil 2fsbk mvfr aw 2f,1 m 0.6 0.8 2 15 -22 10yr4/4 none sit 2fsbk mvfr gw 1fm 0.6 0.8 3 22 -38 10yr5/4 none sit 2msbk mfr cw lvf,f 0.6 0.8 4 - a 7.5yr4/6 none sl ix. 1 msbk/0 sg mvfr /ml dw - 0.4 0.7 5 56 -88 •' 10yr4 /6 none s t 0 sg ml gs - .7 1.6 6 88 1) 10yr5/4 none / s 0 sg dl - - 0.7/ 1.6 a Effluent #1 = BOD? 30 < 220 mg /L a d TSS >30 < 1 0 mg/L Effluent #2 = B013 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur : CST Number James K. Thompson 5.-- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8/21/2009 715 - 248 -7767 Property Owner Richard & Sharon Marr Parcel ID # 040- 1204 -10 -000 Page 2 of 3 3� F Boring # I Boring ✓1 Pit Ground Surface elev. 99.23 ft. Depth to limiting factor >132" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -20 10yr3/2 none sil 2fsbk mvfr aw 2f,1 m 0.6 0.8 2 20 -40 7.5yr4/4 none sl/scl Mb 1 msbk mvfr gw Urn 0.2 0.3 3 40 -61 10yr5/4 none s 0 sg ml aw 1vf,f 0.7 1.6 4 61 -75 10yr4/4 none lvfS 0 sg mvfr/ml dw - 0.4 0.6 5 75 -112 10yr5/4 none s 0 sg dl gs - 0.7 1.6 6 112 -132 10yr6/4 none s 0 sg dl - - 0.7 1.6 143 contains a sil inclusion on north face of pit from 40" - 64". Inclusion is approx. 5'W x 2' H and contains 2cp 7.5yr5/8 redox. concentrations. Inclusion is not present elsewhere in pit. F I Boring # J 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 GFIDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD , 30 mg /L and TSS <30 mg/L 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 (R.07 /00) A.C.E. Soil & Site Evaluations Z � ✓� h E'yyr/�'yy ,Stc. zS T, ze�c , p IP.2ou� T. o 7"�ay, .SE. ClDie Cm., �:Jl. CL Co„vo # os/D- /2o / /o -can c ♦ Ex,:s-6����ade e�e� a. F's.T. c y btalio.�, des % B3 �, o w t Vo EXi'sfrnJ �c�l � 3hcd ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer .�c�G„ -d Sit a- on, Y17a,/r' Mailing Address /A/ Dk 1wrrg4e., �. Property Address (Verification required from Planning & Zoning Department for new construction.) / l City /State 6y4 ' 4 4- ) l Parcel Identification Number 0 120gl /d —lz ,5 - V0.4Z LEGAL DESCRIPTION Property Location 1 /a , *16 1 /a , Sec. -ZS , T _* N R 20 W, Town of - 7;�' : Y i Subdivision /Q/a' f/ e.c.J A, Lot # Certified Survey Map # 4 cZ , Volume , Page # tic, Warranty Deed # s. 773 , Volume _-&I Page # ,W Spec house no Lot lines identifiable yes pw SYSTEM YS EM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/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 stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms i SIGNATURE OF APPLICANTS) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01101). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be 5 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspectc n. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified t) service septic tanks under s. 281.48, Stats. if the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed frc its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank r nholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings use( ar service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Come 183.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or Chem: cal additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of a diversion valve. Valve to be switched diverting effluent from dispersal cell currently in use to resting cell on a two-year cycle coinciding with septic tank inspection and maintenance. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber or the County Zoning Department. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 18/ ,6 , �✓,�, -.�, de, k a4 L u)l s z2- located at: 4,5 1 /4, ng 1 /4, Section 2S , Town ?-d N, Range 2..0 W, Town of 7ov , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /,,oa V"-r Construction: Prefab Concrete P--- Steel Other Manufacturer (if known): o Tank (if known): z vn� rS ;licensed mit umber (if known) Plumber ignature) (Print Name) (Title) (License Number)14P/MPRS (Dat Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3 - 1992 cs tv eaa aacogDZac Data QUI CLAIM DEED ;' SISTER`S 0 C� 526'7'7 Vat.' 4PASE328 sr.cl oDcoo., l Need for Record MAR 1 6 1995 SUS&N A. NIA"., Grantor, quit claims to RICHARD R. MARK, 8# 9-30 A. Grantee, the following described real estate in ,St. Croix County, State of Wisconsin: Relvi ter rf c- asr = To r � Lot 1, Plainview Acres in the Town of Troy. i THIS DEED GIVEN PURSUANT TO THE TERMS OF A JUDGMENT OF DIVORCE GRANTED BETWEEN THE ABOVE PARTIES IN THE CIRCUIT COURT FOR ST. CROIX COUNTY, WISCONSIN ON MARCH S, 1995. This is homestead property. A Drted this A day of N,arcb, 1995. (SEAL,) (SEAL) Susan A. MMAff (SEAL) (SEAL) AdPMINTICATION ACICNOWLIEDGMEN'T Signatures of authenticated this day of, 19 STATE OF WISCONSIN ) SS TITLE: MEMBER STATE BAR OF %YMNSIN � ST CROIX COUNTY If not, __ authorized by 1 706.06, Wis. Stats.� Personally came before ma this - day of March, 1995, above named Susan A. Marr, to ra known to be the persons who exa' Ding T @IS INSTRUMENT DRAFTED BY instrument and acknowledged the same. Robert W. Mudge, Auor=y MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. 110 Second Street, P.Q. Box $02 Hudson, Wisconsin 34016 N b f lic, State o Wlec y mmi"ion expires 1 Try" (Signatures may be authenticated or acknowledged. ScAh are not necessary) '•••• Name of puma eWft irk .w cWw►b eboW to "W or pb W below arolr siawwo.. QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 - 1932 h to q 0 CA p v 0 c °' cc °: 3 2 m 3 m m co a • m xt v (D m ^ j 3 � c o w � 0 ° CO 0 I o m� q °� v o c ° 't �• 3 0 v 3 c W ! E N c� c ° ro Z° a m O m L " rn i N ^� M ft A A CJ 0 O y f� N �• O A S 0 CU _ 1 N c .. C .7 C7 d fD �_ N (D < D m ° (D m a D N y Q Q _ I 07 Cb COJ� O O co �' N CD O O CL --� O O ,wry A OD QI < O CO 00 ;u O N C) N .. C l�r1 <`� ( hi y N N N 0 N N y n cs v v v a tr v v O v < eQ 0) O , O -i A _ m N ? m = m lV Ocr 61 •. N N rte. •• N 3 0 CD D co o D o O O Cl O :p I � I � q g D CD cn ( rn m EO �_ n A CC F4 c (D CD C < CD CD N Q O O 7 i C CD J p Z <D c 0 CL a �' C I N U7 v� vA mOD Q 3 Q 3 P Z °o $ `: � mC) N Z y A CD CD A w A Di m m = v A CD cl CD CL r o o v — _ T 3 v G C N SU C 0 O a D. O a CD p CD (D N fD X (n 0 ' t 7 0 Q. 3 Q a Z' '< O t o -�0 �• CD co F O CD O ID y 3 rn o CD � o I I v A 0 o 3' c � b CD CD oO o O 0 s � 7 Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T , '2 k N -R./9 W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION 0L "` / LOT d' LOT SIZE - s PLAN VIEW Distances and dimensions to meet requirements of I•ZIIR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM zz o � G ��• � E ti'D iEN 11 w Q7 -. 10 p IF /kafTIo.v OF � r 8 r / \0-S r O / � .S . � C � i INDICATE NORTH ARROW IC 4,4A)Af BENCHMARK: Describe the vertical reference point used P OST Of NEi( ,BD/Q 74 N0090K Elevation of vertical referen point: to 3. 7 l ot . Proposed slope at site: 90 SEPTIC TANK: Manufacture r: Liquid Capacity: �6 i Number of rings used: N Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: i Number of feet from nearest Road: Front , Side 0 Rear, O 77 feet No From nearest grope ty line Front,O Side,o Rear, O feet Number of feet from: well , building: (Include this information o t EVERSE SIDE he above plot pl )(2 reference dimensions to septic tank) tdE'if A!O /ti 5���1� � A� 4 Z — /�� EE R r s 1 PUMP CHAMBER , ,dO Manufacturer: Liquid Capa y: Pump Model: Pump /Siphon ufacturer: Pump Size Elev Bottom of tank elevation: Pump off switch eleva n: - � ercycle: Alarm Manufact er: Alarm SwType: Number o eet 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 ABSORPTIION SYSTEM Bed: \ Trench • Width: /1 Length: J 3 Number of Lines: Area Built: i Fill depth to top of pipe: 3. Z S Mopes / � Number of feet from nearest property line: Front, O Side, © Rear,0 Ft / 0 Z Number of feet from well: ee � or / fa / /�t� 1a Number of feet from building: -3oO f4 • 1 .1 � S (Include distances on plot plan). SEEPAGE PIT Size: Number ts: Diameter: Liquid depth: Bottom age pit elevation: Area Built: Has either a drop box O O or distribution box been used on any of the above soil absorbtion sytems? (Check one). i HOLDING TANK Mane Capacity: Number of rings used Elevation o m of tank: Elevatio inlet: Number of feet from nearest property line: Front, O Side, O Rear, Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: • Inspector: 2 Dated: Plumber on job: H License Number: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 ROBERT W QRICWT WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.& MINN. INSTALLER & DESIGNER LIC. NO. 00663 3/84:mj Y DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ' k2CONVENTIONAL E] ALTERNATIVE State Plan I.D. Number: ` Ilt assigned) ❑ Holding Tank El In-Ground Pressure El Mound 3/4" PIPE ON LOT LINE NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION DATE: • ©Q Virgil Delander RR #3, Plai Drive, River Falls, WI S-_ 3_F5 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF, PT. ELEV.: SE NE, Sec.25, T28N -R19W, Twn.of Troy, Lot 1,Plainview Acres Name of Plumber: MP /MPRSW N... County: Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 58948 SEPTIC TANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER Ci p PROVIDED: PROV DE 00 0 ` o 9 � '` ©YES ❑NO S 0 N BEDDING: VENT DIA. VENT MATL HIGH WATER 1 I NUMSFER OF ROAD: PROPERTY WELL BUILDING: I VENT TO FRESH L( n ALARM F OM LINE A IR INLET: OYE ` ❑YES ❑NO NEAREST , 3 7 'S 102.0 DOSING CHAMBER: MANUFACTURER. 7ING LIQUID CAPACITY PUMP MODEL. MP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑NO ❑YES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROL OP AT NA L N;UMBER,OF - PROPERTY WELL. BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑N NEAREST' SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH. NO. OF DISTR. PIPE SPACING: COVER . J INSIDE DIA.. #PITS: I LIOUID BED /TRENCH TREN CHES My�ER L PIT DEPTH DIMENSIONS 1 �3 / .---- GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV INLET E EN PIP LINE: AIR INLET / 5 `7 7- 2 7 � 5 oC FEET FROM /p 2. / / 1 - 3 S J ° c ® S / Q NEAREST t7 f MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER I TEXTURE PERMANENT MARKERS OBSERVATION WELLS. OYES ONO 1 YES ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED. CENTER EDGES. OYES ONO El YES ONO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BEtli /TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV: DIA.. ELEV.. PIP A.: E AN INN ERM1 R I TION I' HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ONO OYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER #F : PROPERTY WELL: BUILDING: FEET FRCMA LINE: ❑YES El NO DYES ❑NO NEAREST Sketch System on R tain in county file for audit. Reverse Side. � SIGNATURE: / — 7ITLE /�. DILHR SBD 6710 (R. 01/82) EZ 'S`Ons'n APPLICATION FOR SANITARY PERMIT {' e � J `Z�Oi X C OUNTY IL HR T OF (PLB 67) UNIFORM SANITARY PERMIT # ausTAV, cAeoa s �rumr�n AELanons —59 A — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNE MAILING ADDRESS l/i�P(r ,PT s �� . vER cif //S �iS PROPERTY LOCATION eFFY SE 1/4 Ne114, S ZS�, T�N, R /9 E (or W T O WN F /P�y LOT;UMBER I BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, K STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedrooms: 3 [] Public (Specify): THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. 1 ! Seepage Bed ❑ Seepage Trench F1 Seepage Pit ❑ Holding Tank J System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: Rf &2 IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound J In Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed i Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (cluare Feet): 2i 6/s �1L X $I 60 y) Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): i ture: /MPRSW No.: Phone Number: RT. 3 VNEIL RD., HUDSON, WE 54016 7307 Plumber's Address: WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. Name of Designer: MINN. INSTALLER & DESIGNER LIC. NO. 00663 COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved - El Owner Given Initial !1 ✓ X Approved Adverse Determination Reason Tor Disapproval: Alternate course(s) of Action Available: DILHR - SBD - 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property y a Location of Property 5(f '�y, Section Z f , T `" N - R W Township -7-.0 Mailing Address s Subdivision Name �� -�-�n U ( GcJ aef Lot Number L ? Previous Owner of Property 4 ? Total Size of Parcel �.Ln Date Parcel was Created M I Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? —� Yes Volume 3 3(-) and Page Number 3 a, as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. -------------------------------------------- PROPFRTV OWNER CERTIFICATION I (We) ce tijy that aett statement6 on thi-6 6ohm arse tAue to the best o6 my (oun) knowledge; that 1 (we) am (ane) the owneh(s) o6 the prwpehty deacAbed in thi.6 in6oAmation 6orun, by vi tue o6 a waA anty deed rcec �ed in the Oj6ice oj the County RegisteA o6 Deedb as Document No. d ; and that I (we) prcesente.y own the paopoaed A to 6o& the sewage diz pozaZ byatem (arc I (we) have obtained an eaaement, to tun with the above deacAibed p%opeAty, 6o& the consttu.ction o6 .aaid bybtem, and the acme has been duty %eco&ded in the 066ice o6 the County RegdateA o6 Deeda, as Document No. ). SIGN URE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) - 117- / / r $ DATE SIGNED DATE SIGNED r� N Z " c1` m CD PD V w � o n o a s H o• m z rA o En ! E (D d gi sl W m Q d W N m F. j I �* :Fs- � 1 O �1 CD r -cf O y cf + cr '� iW �*' p CD w C PD ¢ !Q d G w CD CD p c Q m +^ p a 0 .- �r m m m CD p �t m w D'R p' :O cr w O A p po (D u iN U) co tr1 '� b i0 iN M v A W m e i F m CD e' c+ CA I .w m R p Fy . ° ra UQ ° t3 .° ° p 0 0 im iy co A �y a ty �+ '� C++ y A CD ° p N b .o SD CD C+ trJ m p i a b CD N i w A. .� iw is N A m p = R in i CD • rn 1 0 m c�B ov m vv Ov H Z y m CD iF� ifA Z En + a p m i O i i C b cA m �+ co A a W O O iA iK , ° O .A cf N M N ID CD ei l � m c} O O M V A K w CD i 0 ^ m ep+ m c IA Cl) 0 FL CD aq i U] m tr n iF,• 0 ; N R CD • CD h o b o IS p R G e m c� D R m CY 0 y °� m m w c CD o a �. m p n o m o o ro o o C m y ry � � , i h ,• p H m H F �l m C m P� M p I `4 m iA C D , o as : A � O CY m O N VJ 'A m m N I Q'q :N p m O C am• ► J rv(( et Y H ° cf [n N a c H s c p m 88 p p th m � � N i � p : o r+ 9:� y h ] m m a p o d • Fi ' m n d a 0 fn C' O °• m oil i <D ig 0 a j C t:r !� tD p p m ' cz O m vm, N O O A lrl iU) 5 d hi m a m d m G c+ M C b ct C p` p y �� {�►�.p.•+ m m CO m C N m a m m ?c* pu CO En , H m $ rr m et N y y ro b p ° .w ,A -! iA y m PD m -- �• m 'n cc o G k m o t a m m N Eft fA '° P� ° CrJ m m C i m N `t �- (D ° k d m m A § iA m iC+ m a b ° CD rn w m ` m A m n Q p G cY ' O 'mod : A � o K M p O f m 4 eY _ m cn ' S' Qo v (D p a m p :c) m po To C7 p• m o co m m N R+ m p H CD 14 ° K m rr O �+ H m m R. �mLe� m� 00 N ° m 7r G C m 4 m �1. m �C O er m m b O o O° , ~• R O p En to p o p N CD � car► CD 1� 0:0 A:(a '� pfd n m m (D IID A te LL p c+ 'd m to et ►' 3 A - rs " ps j m a car e* , , CD ' }�• a pp'' o cr as }i y O� m N Q m -! n cNt ^ N m vQ i CD m m ii .-j ST C- 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d � OWNER /BUYER ROUTE /BOX NUMBER t 3 JV- OA- LJ TV Fire Number CITY /STATE �► Vf2.� fA I� S ZIP 'SY6 L i ce` A C PROPERTY LOCATION: ' N C t4, Section �/ T a N, R - W, Town of TA) % St. Croix County, PE►} }��S Lot number Subdivision , Improper use dnd maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con - sists 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 treat- ment stage in the waste disposal system. St. Croix. County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. H o I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED ( / DATE St. Croix County Zoning Office P.O. Box 98• Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address. x � � m o � -• m m g n m c� a3 at° ��w� o in tp 0 C. � o o m N� A �_ m m c, m N , < cn r CD w c° 3 a ooco� w w p O ,< c- RS w i 3 'Za c� Q a o c m O � O p o m O O - o -,a 3 ' < CO c s , ^ 0 - O D C - m Y/ � . Cc, .. O n �= w n n O ( C D L co -.w m m O� C a �m� o...av�uwi C - co � a aw- Uf o , m m •w cn Z m � y m c� CA f n 0 =r w ,.� Z nNm �m m� ?m D V m c m 0 Er :* -, o a m o a s 2 m o -t °-mom m ?a cfl � �r� m y `_ ° C m v =r m �- m 3 a � m_ c a m i m o �cn 0 m m��QrW Z 4 0 0 �, o = w� a w Cl. m p n CD ) C m w � m C= a 0 0 - CL .. a °QC) 9) 16 5 : n � fn o G) 0 0 mO (� 1 g ao� oco� OcM -i o91 a caw ���w�.m � � 3 0 � 0 3 1< a 3' a m 0 0 w 3 m 'a 0 < °4 . m z ®< ' I o r x tJ O o ID M CD 0_ 7= w M 3 p � � 0 C CcOCfl ?K o m - m 0 a� N N f i 113 � a fo � '� 0wv C � B r �mw� Er C ,ommC I D CD =r w c . 3°a o coa Zrm c 3 tT ww ��owwu► o o oa, 3 m wo.tec�� < N tS to a p ^ tD N O > w o w �' � �D w C o =r Q cn m ONO rnm" -4) Z D � to .< w tc Z m SD (D m . = o acc 3� m e o get° n g m wa -- 0 > > w vi w° ac 0 CD C m o C =• O o to W n ic CL tp a? m O ° — to '< 0 =a CO D N om .:cam = w � 0 o w w C! 0. tnc awo wow m-• =o Qr' -► a_aC a -ui �� o� 3 to M. n C �� Q o W W 0 N U N ao= otc c @-amcw CIL c w m C 0 < 5_ ws Z '• DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, CC DIVISION LABOR HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON W BOX 53707 (1-163.090) & Chapter 145.045) LOCATION: SECTION: T0WNSHIP /roft7wcrrA EtT-Y: OT NO.: BLK. NO.: SUBDIVISION NAME: t '/ �/ 2s /T�8 N/R ►9 E (or► W TRoY / 1��Ai v r s COUNTY: OWNER'S 'S NAME: MAILING ADDRESS: 5-1-04,0 i X /� , f '� €IANOf %f 3 ?G>f /,JIll ld R . T; qt k F //s 41i r Sf�a USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DE S: RIPTION E ATION TESTS: I Residence N New ❑Replace I j//r RATING: S= Site suitable for system U= Site unsuitable for system � S & /" virtf-�j 440 / �D/ a s f o • / CONVENTIONAL: MOUND: IN- GROUND SYSTEM -IN -FILOLDIN TANK: RECOMMEND SYSTEM: (optional) s Du &Is ❑u ®s ❑u os ?-u L H os G au ='Xs� DE �a�,���flo��� ,. If Percolation Tests are NOT re uired DESIGN RATE: Q if any portion of the tested area is in the under s.H63.09(5)(b), indicate: CLASS -- I Fl in Floodplain elevation: PROFILE DESCRIPTIONS /N 'DEci:+ 744 . BORINGI TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER IDEPTH . ELEVATION OBS ERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE A BRV. ON BACK.) A A S 7 1 77-2 ' ZJA3 . , .� ✓� TAN Amt' S/ N CS ' D �� . 9y ' ,V. A , S/ /• y QN , o �04 Z. 17 B 3 9 ' "" . d row 0 - •e a •;, 5^411 OC&A-TS fi jt B SI .� 9 ' ?„R,✓ C_ .e3' a . B . S� /.o 'JA a. S , C. t 7' 74;j oE�y Cr B- `J� D d/ Poo 1zo- > �• D �.e . W ;d�. sra /.o' Z4,v c ::c o e- A . e 2 - 1Z 0 ��� o� �.�. , x.33' a . S S •O� J:fv B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- ! 2 ' 1tc— - C Z- ' afireie /,v e " jWfAAW IA.; / P_ a H♦ 0 P-2:7 .3 Z P P- 2 ' . Z 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. fT' A*/r- SYSTEM ELEVATION w _ p' ��— JV/ _ a - L 1 R �1 .. _.. _... ,..... _ _. 3 ! 1 l^. & 01 * b4 _ E It V - t - E J ' 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: HOMESITE SEPTIC PLUMBING CO. 1!l�j�Q_ /f fs ADDRESS: O 'NEIL CERTIFICATION NUMBER: PHONE NUMBER (optional): ROBERT ULBRICHT 3307 M.P.111 � y� L— 1 3n'�/ MINN. INSTALLER & DESIGNER LIC. NO. 00663 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. HR -SBD -6395 (R. 02/82) — OVER — J INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 J i To be a complete and accurate soil test, your report rntrst include: 1. Complete legal description; 2. The use section roust cle3riy 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 systern; 5. 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 separate sheet may be used if desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. 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. Sign the form arid place your current address and your certification number; 12. Make legible copies and distribute 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 med s - Medium Sand Vi(- Well I's Fine Sand Bldg - Building Is - Loamy Sand - Greater Than sl - Sandy Loam < - Less Than 'I - Loarn Bn -- Brovvn *sil - Silt Loarn BI - Black si - Silt Gy - Gray * cl Clay Loam Y - Yellow 5cl -- Sandy Clay Loam R - Fled sicl - Silty Clay Loarn mot - Mottles se Sandy Clay w, - vvith sic - Silty Clay fff few, fine, faint C Clay cc - corrimon coarse pr - Peat mm - Many, m diurn rn - Muck d - distinct p - prominent ` HWL - High water level, Six general soil textures surface water for liquid waste disposal BM Bench Mark VRP - Vertical Reference Point t TO THE OWNER: This sod test report is the first step in securing a sanitary permit. The county or the Department may request verification of This soil test in the fielcl prior to permit issuance. A €;ompiete set of plans for the, private sewage system and a per "nit application rnusl he submitted to the ,approiaaiale local <auihority in order to obtain <a permit, the sanitary permit must be ohtained and posted prior to the start: of any construction. Z- � ',•S /0 3 .7 PL B (p 7 20 MOT anJ CROS5 No. or L, aE S PANS lei- fi go z Oy w 1 pt j • 4� 0 3a --, - ---- •3 Fr Zv�� S °,. • tS I ' ��f osF P,P C J-�T �-,Aiw d /E Xr-LIS Wk :4( LA P PER SIGNED L %?E.vS, ic - ZW if PS Fresh Air Inlets And Observation Pipe -S OIL T E STt Ng By HOMESITE TESTING Co. Approved Vent Cap RT.,3, t7'i' m Rp., r� HUDSON, WIS. ;54016 Minimum 12" Above o Final Grade v+, %l A DM yz-" Above Pipe 4" Cast Iron i io Final Grade Vent Pipe Marsh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution � Tee S o, ,� Pipe 0 0 0 0 0 Ce " Aggregate S o Perforated Pipe Below T� Beneath Pipe 0 Coupling Terminating At Bottom Of System Fr . y7� l . S - ME S W s € t All 4� s= l lx�f LA. 0 m m $ �a Y 1 LLI LLI zip T ; j. k N z _ 'z Y1. W D �C � y ,{P {' 6 o '�i•, Y?° �g M ° O � an C� 1@ i ¢ Y `!', g SS a 2 HWW °n �� 6 w �� 2 Co:� l �ro a s a _X F' � �}y ^ s's�� °er te r' 3 =i' L!?IINI IQI I:II z gy " °N O O¢ ,�j$ N +,OnY wn3f -N• o§ ^ d0 W f W W L1 Y1 - p �p n. < i�ep� <� f a s t>3 ° 3 f ; 3s z Yio o oMa, < -Won e ZA- agw $:8Sti a n�a w O N $ w z z n z z z zz w a `o €E °gs �FOi4okzu It B C. H og N p 00 �O slot F a J • ^� n �� s n .. 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