HomeMy WebLinkAbout040-1219-20-000 (2)STC - 10 4
AS BUILT SANITARY SYSTEM REPORT
OWNER 7
ADDRESS �0 � �' �J7'
Zr
N P
L�0?
SUBDIVISION CSM# A 4,04.41 LOT
SECTIONAf T N-R�W Town of 01
101 - 10 (0"03
ST, CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
2-
��
�1;f
well
d'o
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i
BENCHMARK:
Cam.
ALTERNATE BM: �
SEPTIC TANK PUMP CHAMBER HOLDING TANK INFORMATION
Manufacturer: ee /_,� 0 1/
Liquid Capacity:
Setback from : We 1 1 - Douse 7 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/circle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 4.L- Length LdDumber of trenches
Distance & Direction to nearest prop. line . L�
Setback from: Drell. f House other
ELEVATIONS
Building Serer ST Inlet,.- � ST outlet
PC inlet Pc bottom Pump off
Header/Manifold ?,�AeBottom o system
Existing Grade � Final grace
LATE OF INSTALLATION: ,,5-- ..�
PLUMBER ON JOB:
LICENSENUMBER:
INSPECTOR:
'3:jt
:SANITARY APPLICATION
[ a::Q 14R In accord with ILHR 3.�, VMS. Aden. Code g
aj tv
ylil
STATE SANITARY PERMIT 0
L-Attach complete P*S to the county copy only) for the system, on paper not, less than
8% x 11 inches In size. k , � �� � &P/
bok if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I. .
o NMBF-R
L APPLICANTINFORMATION-- PLEASE PRINT ALL INFORMATION,
FRCP 3 ER PROPERTY LOCATION
CY4 &k26 %, S T
E (ore!V
00fi
PROPERTY�EWS MAILI AD FWESLOT'BLOCK
#
22a
CFT1 AE - ZIP CODE PHONE NUMBER SUBDIV ION DAME OR C AA NUMBER
pvdv� — 91),
_9osio
elog - AFF"
fl. TYPE OF 11 DING: (Check ones OState OwnedVILLAGE:= DEAREST RO
AWL
Public ! 1 or 2 Fam. Dwelling -*of bedr 3
os u
IN. BUILDIN R E. (if building type is public, check all that apply)
1 ❑ A pV ondo
2 ElAssembly lull 60 Medical Facility/NursingHome .
1 � Outdoor Rereat�onal Facility
3 ❑ Campground 0 Merchandise- Sales/Repairs
1 1 ❑ Restaurant/Bar/Dining
Church/School 3 El Mobile dome Parr 1Service ceStation/Car Wash
❑ Hotel/MotelW. Office Facto
ry 13 EJ Other.. Specify
I . TYPE of PERMAIT: (Check only one in lilts A. Check line-B if applicable)
A 1.2 New. 2.0 Replacement 3. EJ Replacement of
p . 0 Reconnection of 5.0 Repair of an
System System. Tank Only Existingstem Existing P
]�system
B) EJ A Sant Permit eras revio 1
` p � issued. Permit #� date issued
V. TYPE of SYMNI: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed - 21 El Mound 30 El T e i
� f R 41 0 i�old ing Tank
12 Seepage Trench 22 El In -Ground 2 0 Pit Privy
13 El Seepage Pit Pressure
. - 43 Vault Privy
14 System�ln-Fil'l
III. ABSoR T N R STE 1 `INFORMATION:
1. GALLONS PER DAIS 2. AB ORP. AREA 3. ABS RP. AREA 4. LOADING RATE . PERC. RATE
■ SYSTEM ELEV.l� . FINAL GRADE
REQUIRED (sq. PR I SED sq. f#. (Galsldaylsq. ft.), (Min./inch) ELEVATION
N
1Y ire T 7.1 CP E -
Feet Feet
W. TAI�IK CAPACITY Site In al lobs Total ## Manufacturer's Name Prefab. C n_ Fiber E r
IFRTIM- lVev. Gallons Tanks o Steel Plastic .
Tanks Tanks
ncre structed glass APp-
Septic Tank or Holdin Tank .00
Lift Pump TankfSi h(yn Chamber ff
Vill, RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite
Z
r'a Name (Print): Plumber's Signature: (No Stamp
r s dress te, Cam):
fx. OUNTYf DEPA TM NT S5
Disapproved
21 Approved ❑ owner Given initial
A.
itary Permit Fee 0ncludes Gmndwaw
Surcharge Fee)
* CONDfTKM of APPROVALIREASONS FOR DISAPPROVAL:
system shown.on th'e aftched plans.
T
MBI PRS1 I .: Business Phone Number:
POI 0? . 71 7�010) .07� Xd
5 —,0?441
{
ing
SBD48M {i nnerly Plb 'T) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. ' Arari1taF*,,permit is valid for two () years.
rt
. r s nFtary permit may be renewed before the expiration date, and at the time of renewal .an new
criteria in the Wisconsin Administrative Code will be applicable,
. All revisions to thi8 permit mast be approved by the permit issuing authority.
. Changes to ownership or plumber requires a Sanitary Permit Transfer/renewal Form BD 399) to be
--.} ubmitted-to the county prior to -installation•
4
• Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
i
pumper whenever necessary, usually every 2 to 3 years. -'
If you have questions concerning your onsite sewage system, contact your local code admini tr for or the -
State of Wisconsin, Safety & Buildings Division, - - 81 . _
To be qornpletiB and accurate this .san-itary permit applicetion 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.
IL Type of building -being 'served. Check only one and complete of bedrooms if 1 or Family Dwelling..
Ill. Building use. If building type is Public, check all -appropriate bones 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,
I.. 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.
NIP, etc.), address and phone number. Plumber must sign application form.
X County/Department Use only.
X. County/Department Use Only.
Complete plans and specifications not smaller than '/2 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 bones; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
D} complete specifications for pumps and controls; dose volume; elevation differences; friction lass; pump
performance curve; pump model bnd pump manufacturer; D) cross section of the soil absorption system if
:.required by thy=county; E) soil test data on a,11 form; and F all. sizing information.
GROU GYI ATE/ ' SURCHARGE
1983 Wisconsin Act 410 included the creation of su:rch rg es (fees) for a number of
regulated practices which can effect groundwater.
The monies collected .through these'.surcharges are used for monitoring. groundwater, ground-
wate r'cO''ntaM ination investigations and establishment of standards. _
BD- 398 (R _ 11188)
r �
r
I
DRVE FOG KUIMNG
e* Tom ' & PlWnW
M
MAC99Road
54023
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welf 7 O
LQqOW a rtXgW(Ir1 st . 19 j, ICE rRISE ?FV891Effiffm
Labor and Human RelationsINPET�ON REPORT
Safetyand Buildings Division
(ATTACH TO PERMIT)
GENERAL INFORMATION
Permit Holder's Name: city ❑ Village 1iTown of:
lev.: insp. BM Nev.: BM Description:
00 - /60, 0 4 4-0,v., I
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER TURER APA STY STATION
Septic
/,
en hmarK,�Je,
Dosing
Aeration
Bldg_ Sewer
Holding
St 1 Ht Inlet
TANK SETBACK INFORMATION
`t1 Fit Outlet
TANKTO P 1 L WELL BLDG.
Vent to ROAD
AirIntake
Dt Inlet
Septic I 170
NA
Dt Bottom
Dosing
NA
Header/Man.
Aeration
NA
Dist. Pipe
Holding
Bot_ System
PUMP / SIPHON INFORMATION
Final Grade
Manufacturer
Demand
f
Model Number
PM
TDH Lift
Friction/
5ystem
TDH Ft
Head
For emain
Length Dia.
Dist. Towel
A9300021 3
HI FS ELEV.
7.
r
SOIL ABSORPTION
h Length No. f Tr aches PST No. Of Prt inside Dia. Liquid Depth
BED/TRENCH Width 9 DI�IAEN I11�
DIMENSIONSManufacturer,
SYSTEM T P I L BLD WELL LAKE/STREAM LEACHING
SETBACK CHAMBER
NAodel Number*INFOR CATION Type � � r � l OR UNIT
yste.m.: �•
DISTRIBUTION SYSTEM
Header ! Manifold Distribution Pipes} x Hole ire Hole Spacing Vent To Air intake
k
JV p
Length DIa_ �f Lengthl� �I�_ � ���Ifl�
Pressure stems Only Mound r At -Grade Systems Only
SO�L0JR ]�
Depth Over Depth f xx Seeded I Sodded xx 4ulched
Depth Over R Yes 0 o
Bed 1 Trench - BedlTrenchEdges �" 3 Topsoil yes � N �
COMMENTS: (Include code di crepanCie% persons present, etc.)
L OCATIO*
N. 8,28,191NENWr,
LOT 2, RED BRICK I"
L00- --A 1A 15 21 A0 0 sbA 6 0
4, 16
Plan revision required Yes] N
Lf se other sNd
for additional inforrntio
Date QJ inspector's signature pert_ No.
Mill
C� ILHR SANITARY PERMIT APPLICATION
p In aeeorE with IIHH 83.05. Wis. Adm. Code
-Attach complete plar)s (to ft county copy only) for the system, on paper not less than
% x 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P17me RTY OWNER PROPERTY LOCATION
PROPERTY OWNIIAAi ING ADD ESS LOT
CITY STATE ZIP CODE PHONE NUMBER SUBDIVIISION NAME OR em
II. TYPE OF BUILDING: ' heck one CITY =
State Owned ILLAGE ; 77? 0
...E]Public 1�rl or 2 l=am. Dwelling-# of bedrooms ARCEL TAX I
III. BUILDING USE: (H building type is public, check all thatapply)
1 ❑ Apt/Condo
2 ❑Assembly Hall 6 El Medical Facility/Nursing.
Home
3 ❑ Campground 7❑ Merchandise;
Sales/Repairs
Church/School 8❑ Mobile Home Park
❑ Hotel/Motel g El Office/Facto
IV. TYPL OF PERMIT: (Check only one in lure A. Check line S if applicable)
A) 1. New _ . E1 Replacement p cennent . 0 #lplacernent of
-System system - - Tank Only
S El A Sanitary Permit wasPreviously •
sued, Permit #
V. TYPE OF SYSTEM: (Check only one)
STATE SANITARY PERMIT
0 to previous application
TRITE PLAN I.D. NUMBER
T.O. ', No R E(o!e&
BLOCK #
NEAREST ROAD
10 El Outdoor Recreational FaciIity
11 ❑ Re taurantlBar/Dining
12 ❑ Service Station/Car Wash
13 ❑Other: Specify
4. 1:1 Reconnection of
Existing System
Date Issued
Non -Pressurized Distribution Pressurized Distribution - Experimental
11 ❑ Seepage Bed 21 El Mound 30 El
Pecf y Type
12 Seepage Trench 22 11 ire- round
1 Seepage Pit Pressure
14 El System -in -Fill
. 1:1 Repair of an
Existing System
Other
41 ❑Holding tank
42 1:1 Pit Privy
43 El Vault Privy
V1. ABSORPTION SYSTEIIA OM.RMATIDN:
1. GALLONS PER DAY
1
2. AB MP. AREA
-REQUIRED(s %)
& AB ORPt-AREA
PROPOSED
4-LOADINGRATE
S.PERC.RATE
6.sySTEMELEV.
7. FtNL GRADE
.
sq. ft,
1
(Gals/day/sq. ftj
(Min./inch)
ELEVATION
51's-4
5".TY�
P 51,
VN. TANK
CAPACITY
-7Z
L Feet
Feet
Feet
INFORMATION
In g Ions
i
Total
Gallons
Tanks
�►Aarrufacturer's Name
Prfarb.
Site
Goa-
steel
Fiber-
Plastic
Eper.
Tanks Tanks
anks
r r
stru ted
glass
App-
Septic Tank or PWdinn Tonir
•.V
A&M
.0 e .
Lift Pump Tank/Siphon Chamber
1f11I. RPDNSISILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite
P1u r'a Name (Print): Plunfber's Signature: (No Stain
19 Address (#reet, City
system shown on the attached plans.
MFVMPRSW No.: Business Phone Number.
r az1 7 Z r-Z
DC. COUNTYIDEPARTMENT USE ONLY �7
'0' U Dlaapp reed Sanitary Permit Pee trcharge
kwes eroundwat� Issuing A nt Si a re { Stam
Pry ❑ Owner Given Initial Fee)
agve
71��
X CONDIMNS DP APP OVAUREA ONS F DISAPPROVAL
iw
"600'Cla-' Cy -66
ar-�6
8D- M (formerly Plb-M (R. 11/80) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
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
Location of pr?perty 1/4 Section
Township
Mailing address F-- 076
Address of site
Subdivision name
Lot no.
Other homes on property? yes- No
Previous owner of propert
y
Total size of parcel
Date parcel -was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
Volumes Volumes -and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. 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 Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded the office of the County Register of
0�r� . -_�'
Deeds as Document N.
and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recordede* J3 e o office f
Lf8 County Register of deeds as Document
No.
Signatuo applicant Co -applicant
i)p
77
Date of Signature
Date of Signature
DOCUMENT NO. TW SPAa ftUW40 FOR M.00P NG DATA
-WARRANTY DEED
STATE BAR OF WISCON IH FORM 2 - 1982
484795
David , Knighton
conveys and warrants to
Delta Construction a M Corporation
MeFot r dmdbed reef egate In .__ n9.n..=ix r.. County.
State d IAlisconsky
Lot No. 2, Clearview Addition
REGsrISTER'S OFFICE
. CROIX C0.0 w
a Rsc'd Far Rsoord
JUN 171932
d 3:20 P. M
0 an4%tA
Tax Parcel No:
Subject to Declaration Establishing Protective Covenants and other easements
of record.
This is a x t pra"Ity.
091 (is no
Exception to warranties;
Cat is 1st day June 1992
V
David R.Kniq tan
(SEAL) ISEAL)
AUTHOMCATION ACKNOWLEDGEMENT
Minnesota
S+gnaturels) STATE OF
sa*
Henna in County.
Farsonaly came before me this Est day of
authenticated this day of .19 Jurle. 19 the above named
David R. Kni htori
TITLE: MEMBER STATE BAR OF NSCCNSiN
(if not, to me known to be the person who executed the
authorized by 1 . , WI& Staffs.) k i rA V c ledge the same.
THIS INSTRUMEW WAS DRAFTED BY
David J. Butler Attorne • David J. Bugler.
e Ave So,, Suit:6-5-26,,
Richf field, M . 55423' Notary Pubk IKUMcin County a. ly
Segnatures may be autf nticceted or w*wwWged. Bath my com ex�irat n
are not necessary.) wa r re» , 1
f
'Names of wwftrwrq in any c ar shoA be "W or prWW blow vwr sommAreL e
WARRANTY DEED STATE BAD# OF MSCONSIN . i+vtSCONSW REALTORS* ASSOCIATON
FORM ND. 2 - 1982 4WI Hayes %&d. MadiSM1+ftcWsin 53704
I
04 ._M if
DAVEWOIM*d park r & WONG
Rad
RO;EIN�540?3
Phone
`d
1
rhz- s2n.:rltn
rt
7
A
Moro
�e
-�
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St, Croix County
OWN BUY
ADDRESS FIRE NUMBER
CITY/STATE9 ZIP
PROPERTY LOCATI011:A L114,i 1/4, SECTION -R W
- a - N
TOWN OF St. Croix County,
SUBDIVISION LOT NUMBER
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 l'
A r icensed 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 nay be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system, which was in operation pricer 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
system prope.rly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification form, signed by the owner and by a water 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.
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 DNR.
certif ication stating that your septic has been maintained must be
completed and returned to the St. Croix Co, �pnin g Officer within
30 days of the three year expiration date,,
SIGNED
'OLA4
DATE: t s
St. Croix co. zoning office
911 4th St.
Hudson, W1 54016
DEPARTMENT OF
INDUSTRY,
LABOR AND,
HUMAN RELATIONS
REPORT ON SOIL BORINGS AND
PERCOLATION TESTS (115)
IILHq 03.091118 Chapter 1451
SAF ETY & BU I LD I NGS
DIVISION
P.O. BOX 7969
MADISON, WI 53707
LOCATION:
4,*w V4
ECTI N:
V ITW N/R /? E
0WNSHIP!
TrF 49
OT NO.:8LK. NO.:
SUBDIVISION NAME.
c�e& K VI"e4AJ
COUNTY:
LO I
BUYEROS NAME:
w
e I c07,
LING ADDRESS:
4z,S%h
USE uAI t4 uts*trtvs411urob M#kvt
�Resid$nce
NO. BEDRMS.: COMMER tAL DES RIPTIO P NS: PERCOLATION TESTS:
L]CIIVeuv �Reptace
3SL4r a
RATING: S= Site suitable for system U- Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PPR SYSTEM-IN-FI L OLOING TANK: RECOMMENDED SYSTEM: (optional)
CSD[I [ISCII Eg_S
❑U OS EIS �,;hVr� zw.e! rz
If Percolation Tests -are NOT required DESIGN RATE: If any
portion of the tested area is in the
unders, I L H R 83.0915)(b), 1ndicat Floodplain, indicate Floodplain elevation.
PROFILE DESCRIPTIONS
BORING
NUMBER
TOTAL
'DEPTH IN.
ELEVATION
QEEIH TO GR UNDWATER-INCHES
EST. PTUW
CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.)
OBSERVED
B-
S + �7 'Br, � . #.. 4 c� .
!-!
•
C%
41
/ If rf f f f� r
/
F& f�It f L Lip ? f G
B-
e—
r L r
PERCOLATION TESTS
TEST 1
NUMBER
DEPTH
INCHES
WATER IN HOLE
AFTER SWELLING
TEST TIME 1
INTERVAL -MIN.
DROP IN MEN LEVEL-INCHEs
RATE MINUTES
PER INCH
PgRIQ0 1
P
P_
S
C__
P_
p.
t
tr
#
P-
P- ,3
S
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. Shove the surface elevation at all borings and the direction and percent
of land sl pe.
SYST III ELE"TION
! + A t
a
,
'Pod
S � 3
-
+
I
S
I I4.
,
r.
i
' 1
_....._............ ... ..._ ., ........_311
II 3
0.1
yr
e
r
i
r
.... .. .... ...... `¥
r { r' fr`
_-........ ..,...I ............ A .._. ... i.....
trick
I, the undersigned, hereby that the soil tests reported on this form were made by me in accord with the procedures nd ,hlk6s specified in t i Hein
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and beli dr
NAME (print): TESTS WERE COMPLETED ON:
DAVE FORTY PLUMBING 4bo Z
ADDRESS: Ucermd PGFk Tester & Plumber CERTI CA ION NUMBER: PHONE NUMBER optional):
ROBE WISCON IN 54023 JCSTNATUPFr.�
Phone 749-365691 14
DISTRIBUTION., Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) — OVER --
T�
ti SD
PAYE FOGERTY pLUMBING
Ucenwd Perk Tester & plumber
#3233 #3289
ap Heights
P r Road
749 ROSEWSO WIphwe 3656 5023
e-. 1,
4* >
14
/Me r5
C47 6y
DAME FOGERV Y PLUMBING
Licensed Perk Tester &Plumber
#3233 #3289
Fogerty Heights RoadROBES, WISCONSIN 54023
Phone 749-3656
1EPT1 1 TROY ST. OP IX COUNTY ZONING PAGE 1
0 1 9 16:19 REQUESTS FOR INSPECTION WORK SHEETS FOR. 5 1/ 9 AREA: Nam'
. Activity: A9 - 00 1 5 1' 9 Type: CONV93 Status: : PENDING Constr.
Address: TROY18,281191NEINW, ITT 2, RED BRICK
Parcel: 0 0-1 19- 0- G Use;
Description: 1931
Applicant: DELTA CONSTRUCTION Phone
Owner: DELTA CONSTRUCTION Phone
Contractor: FOGERTY, OATIB B. Phone: 749-3656
Inspection Request Information.....
eq estor : F GE T , BAVIB Phone
eq Time: 15:05 Comments: ' �3
Items requested to be Inspected... Action Comments Time Ep
00012 FINAL INSPECTION
i �r��i� �F! �! �f �f !!!! �►�!F! 1����i� i�4 �� � �F �F �!� i i i i�i i �_�_ i� �FYYi ��F i,�lir�ii� lei, ii i i �i i i i i! i i! i i i i i �i!
Inspection History.....
Item: 00012 FINAL INSPECTION
OF
SAFETY & BUILDINGS
RE ON SOIL BORINGS, AND DIVISION
DEPARTMENT
INDUSTRY,
AND
-PO — P.O. BOX 7969
���,�LATION TESTS (10) MADISON, WI 53707
L-A60R
HUMAN RELATIONS
(I LH R 83-09 (1) & Chapter 145)
�%l
T NO.: BLK. NO.: SUBDIVISION NAME:
OCATIOW. SECT14DN/: TOWNSHIP/
'/4 Nkl1/T;y/Rly E
=L=rj
COUNTY: /BUYER'S NAME -MAILING ADDRESS:
OBSERVATIONS MADE
17i:::F ITE DESCRIPTIONS: TESTS:
USE PJ- BEDRKC
hkL D CRIPT10NhXewReplace
_
[Residence
3
4&LAlTION
a
N�4
RATING: S= Site suitable for system
U= Site unsuitable for system
URE- SYSTEM-1 N-F ILLH LDING TANK: RECOMMENDED SYSTEM: (optional)
_-6_R0_�_PE_RES
CONVENT I ONAL: OUND-
S 7�
U ES
1 0& US El S [2b [:1 S FLAM e
If Percolation Tests are NOT required
Percolation
0 tl
Fu'fndee
SIGN RATE: It any portion of the tested area is in the
DESIGN Floodplain, indicate F[oodpla'n elevation'. A
under 13 L H R 83.09 (5) (b), i n di c atW'�4
PROFILE DESCRIPTIONS
PERCOLATION TESTS
-------
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL -INCHES R QD3
0021
-- PE
RATE MINUTES
PER INCH
NUMBER INCHES AFTER SWELLING INTERVAL-MINN. PER10D 1
P_ /k C_
P_
P_ 2-
P_
:5 -2 . .......
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describewhat are the hori-
Show the surface elevation at all borings and the dection and percent
zontal an vertical elevation reference points and show their location on the plot plan.
of land sl e.
SYST M ELEVA ION
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1, the undersigned, hereby certify that the soil tests reported on this form were rnade by me in accord with
to the best of my knowledge
d
�
the procedures
and beli
th specified
Administrative Code, and that the data recorded and the location of the tests are correct
Phone 749-3656
DISTRIBUTION: original and one coPY to Local Authority, Property owner and Soil Tester.
DIL'HR-SBD-6395 (R. 10/83) — OVER —