HomeMy WebLinkAbout026-1056-90-000 (2)County Planning and ZonisSt. CroixMondiq,fuh, 11, 2005 at 3:3 7:33 PJ1
Detail Sanitary In Page I of']
Computer #: 026-1056-90-000 Sub/Plat: metes & bounds Section: 19
Parcel #: 19.30-18.287E Lot: TN/RNG: T30N R18W
Municipality: Richmond, Town of CSM: 1/4 1/4: NE 1/4 SW 1/4
Owner, I st National Bank of New Richmond 1432 95th Street New Richmond, WI 54017
State Permit: 149194 Issued: 09/24/1991 POWTS Dispersal: Non -Pressurized In -ground Permit: Replacement
County Permit: 0 Installed: 09/24/1991 POWTS Detail: Bed - Seepage Bedrooms: 3 WI Fund:
POWTS Pretreatment: NA
Notes ArIc-i-i—al Notes Money Owed
Inspector As Built Plumber -Other Requirements --l-, .- L �-- i I
Not determined Yes Bird, Byron Jr. check archives - soil report still in active file - $0.00
Signed Off. No notecard and soil report filed with permit
Maintenance
Scheduled Pump Date Pumped 1 st Notification 2nd Notification 3rd Notification
9/24/2005
Parcel #: 026-1056-90-000 07111/2005 03:32 PM
PAGE 1 OF 1
Alt. Parcel #: 19.30-18.287E 026 - TOWN OF RICHMOND
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
* BACON, JASON E
JASON E BACON
DEWOLF MEGHAN P
DEWOLF MEGHAN P
1432 95TH ST
NEW RICHMOND W1 54017
Districts: SC = School SP = Special
Property Address(es):
Primary
Type Dist # Description
1432 95TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres:
2.250
Plat: N/A -NOT AVAILABLE
SEC 19 T30N R18W PT NE SW COM 2147.75'E
Block/Condo Bldg:
OF W 1/4 COR SEC 19; TH S 28 DEG W
1062.08'POB; TH S 28 DEG W 503.4';TH N
Tract(s): (Sec-Twn-Rng
40 1/4 160 1/4)
69 DEG W 89.8'; TH N 08 DEG W 204.5'; TH
19-30N-18W NE SW
N 08 DEG E 217.24'; TH S 88 DEG E
326.0370 POB 2.25A
Notes:
Parcel History:
Date Doc #
Vol/Page
Type
07/02/2002 683275
1921/170
WD
07/19/2001 651594
1683/400
WD
02/07/2001 638132
1584/171
WD
07/23/1997
962/92
more...
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/19/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.250 41,900 79,900 1211800 NO
Totals for 2005: General Property 2.250 41,900 79,900 1211800
Woodland 0.000 0 0
Totals for 2004: General Property 2.250 411900 79,900 1211800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 131
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
ILDINGS
N SOIL BORINGS AND SAFETY & DIVVISIONISION
aE`PARTMENT OF REPORT O
INDUSTRY, COLATION
����� P.Q. BOX 7969
LABOR AND E (115) MADISON, WI 53707
N RELATIONS
L!•i R 83.09(1 ` &Chapter 145)
OCA IONS SECTION: ;OWNS HI UNICIPALITY: OT NO.:BUC-NQ.: SUBDIVISION NAME:
1/ M N/R� (or
COUNT Y
jo xyll�
MAILING ADDRE S: c
.,,.,,
USE rC - DATES 013SE RVATIONS MADE a G
���}}NO. BEDRMS.: COMMER IAL DESCRIPTI N. RCOLA E TS:
AResidence ,,,�_ ❑New Replace
RATING:S S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN -GROUND -PRESSURE: SYSTEM -IN -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ,j".ji
Elu
KSEA
MS EA 0 S UH0 S [A y r
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
ROFILE DESCRIPTIONS
PERCOLATION TESTS
P OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distanm. Describe ',what are the hori-
r Mal and vertical elevation reference points and show their location on the plot plan. Show the surfaqe elevation at all borings and the dire4tion and percent
land slope.
YS EM ELEVATION ..
__
11 �
iW_.
a
I
p f t
{
:
:
t �-r
? �+
3
e
the undersigned, hereby certify that t his farm were made by me in accord with ;he procedu s anp methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correc y k f.
NAME (print): ZY t
ADDR
TESTS WERE COMPYETED ON:
�_ —
CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGN U E: /J
DISTRIBUTION: Original anti one copti, to Local Authority, Property Owner and Soil Tester.
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER--,VOWNSHIP
SECTION- _T N - R W
ADDRESS /4%' ST. CROIX COUNTY, WISCONSIN
,
SUBDIVISION
PLAN VIEW
LOT LOT SIZE,
SHOW EVERYTHING WITHIP 100 FEET OF SYSTEM
v
tv.
INDICATE NORTH ARROW
BENCHMARK: Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: -e Liquid Cap. Z4>2,-fto.7tom
Rings used: r Manhole cover elev: -Final grade elev:
Tank inlet elev.: Tank outlet elev.:
"
No. of feet from nearest road : Front -, Side // Rear Ft._
From nearest prop. line:Front . Side _ , Rear Ft.
No. of feet from: Well
. Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev. Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front Side , Rear Ft._
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: Length Number of Lines : ,-'Area Built `-
Exist. Grade E 1 e v . ._Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop, line:Front Side Rear Ft.
No. feet from well: No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front Side Rear Ft.
No. feet from: Well , building nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB: .
LICENSE NUMBER:
6/90:cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM
Labor -and Hur0an Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL I INFORMATION SWI (ATTACH TO PERMIT)
4,SW14 ,Sec.19,T30-R18,95th St.
i [X
Permit'Holder's Name: EJ City 0 Village Town of:
'irst Nat'l Bank/New Richmond Richmond,
CST BM Elev.: Insp- BM Elev.: BM Description:
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
or
Dosi ng
Aeration
Holding
TANK SETBACK INFORMATION
TANK To
P/L
WELL
BLDG.
Vent to
Air Intake
ROAD
Septic
150
c3c;�
NA
Dosing
NA
Aeration
NA
Holding
PUMP/ SIPHON INFORMATION
Manufacturer Demand
Model Number GPM
TDH Lift I Friction 5ystem TDH Ft Loss Head I
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County -
St. Croix
Sanitary Permit No.:
1 491 94
State Plan ID No.:
Parcel Tax No.:
0 2 6-10 5 6— 9 0 287E
XLE! !_/7 Mor, 9�� 0/3 VWJFFAI YeA rA
STATION
BS
Hl
FS
ELEV.
Benchmark
Bldg. Sewer
St/Ht Inlet
-7 Cl
St 1 Ht Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot- System
Final Grade
ni
6
V
BED/TRENCH
Width
Lenqth
No. Of Trenches
PIT
No. Of Pits
inside Dia.
Liquid Depth
DIMENSION
DIMENSIONS
SYSTEM TO
P / L
BLDG
WELL
LAKE STREAM
LEACHING
manufacturer'.
SETBACK
INFORMATION
CHAMBER
OR UNIT
TypeOf
>
T
Model Number:
tSystem : 71,�"
I
DISTRIBUTION SYSTEM
Header / Manifold Distribution PlDe(S) x Hole Size x Hole Spacing Vent ToAir Intake
Length 6 Dia- /I/ Length ?61 Dia. L_, I Spacing (�
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded
Bed /Trench Center Bed /Trench Edges Topsoil 0 Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
xx Mulched
El Yes 0 No
Plan revision required? El Yes El No
Use other side for additional information_
SBD-6710(R 05/91) Date Inspector's Signature Cert. No,
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILHR
SANITARY PERMIT APPLICATION -
In accord with ILHR 83.05, Wis. Adm. Code
—Attach complete plans (to the county copy only) for the system, on paper not less thar
8% x 11 inches in size.
—See reverse side for instructions for completing this application.
I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATIOw9e�
OPERTY LAOCATION
PROPERTY OWN
rt /ec 2/01i7jv� 'o eco
PROPERTY OWNER'S MAI ING ADDRESS Ldf #
4c--
COUNTY
STATE SANITARY PERMIT #
(i 9q
CZck 4ie ?ion to previous application
STATE PLAN I.D. NUMBER
T7t) I No R E (or
BLOCK #'
CITY, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER—_
-7/ LIZ
El CITY NEAREST ROAD
II. TYPE OF BUILDING: (Check one State Owned VILLAGE
FV-1 TOWN 192
El Public InO 1 or 2 Fam. Dwelling—# of bedrooms CEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply)
1 E:1 Apt/Condo
2 0 Assembly Hall 6 El Medical Facility/Nursing Home
3 El campground 7 El merchandise: Sales/Repairs
4 M Church/School 8 E] Mobile Home Park
5 El Hotel/Motel 9 El Office/Factory
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. El New 2. [RReplacement 3. 0 Replacement of
System System Tank Only
B) El A Sanitary Permit was previously issued. Permit#
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution
11 E3�-Seepage Bed
12 ❑Seepage Trench
13 ❑Seepage Pit
14 ❑System -In -Fill
Pressurized Distribution
21 El Mound
22 n In -Ground
Pressure
10 ❑Outdoor Recreational Facility
11 El RestauranVBar/Dining
12 ❑Service Station/Car Wash
130 Other: Specify
4. ❑Reconnection of
Existing System
Date Issued
Experimental
30 ❑Specify Type
VI. ABSORPTION SYSTEM INFORMATION:
- 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.)
CAPACITY
VII. TANK inqallons Total # of Manufacturer's Name
INFORMATION New xistingj Gallons Tanks
Tanks I Tanks I
5. El Repair of an
Existing System
Other
41 ❑Holding Tank
42 ❑Pit Privy
43 ❑Vault Privy
5. PERC. RATE G. SYSTEM ELEV. 7. FINAL GRADE
(Min./inch) ELEVATION
,or /
.04 oz-- Feet /i�?, o Feet
Prefab. Site Fiber- Exper.
Concrete Con- Steel glass Plastic App.
structed I
Septic Tank or Holding Tank I IA/ -CL—SLA I
Lift Pump TanklSiphon Chamber
Wa
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber:iature: (No Sta MP/MPRSW No.: Business Phone Number:
zqv
'Plum-Fer;d Address (Strea, C;ity, State, Zip Code).
O
A -A- -
-7
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved S-a 'tary Permit Fee (includes Groundwater Date Issued Issuing Ag t bignatur No Stamp
Surcharge Fee)
Approved F7 owner Given initial
17
1 Adverse Determination. j
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
i
� r
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 an newy
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this perrnit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 5399) 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:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the syterrrisv be .ihstafld-. • .
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. 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% 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 tanks), 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
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)
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 Mht) XZZ/ 6,k& 6 f Al&d P) o
Location of property 1/4, Section Ale)
T N - R W
Township Iq 4,&cj2d
Mailing address
Address of site
Subdivision name Lot no,
Other homes on property? es— No
Previous owner of property 'In 11
JF
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 V/No
Volume and Page Number as recorded with the Register
of Deeds.
c'n-F:E,-e' C�
--------------------------
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 in the office of the County Register of
Deeds as Document 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
recorded in the office of County Register of deeds as Document
No.;
Sian
Date a . f Signature
Co -applicant
Date of Signature
47is7o
VOL 90(iPpa 24"0
SHERIFF'S DEED ON FORECLOSURE
WHEREAS, pursuant to a Judgment of Foreclosure and Sale rendered in the Circuit
Court of St. Croix County, Wisconsin, on December 26, 1990, in an action between:
FIRST NATIONAL BANK OF NEW RICHMOND9
PLAINTIFF,
vs, CASE NO, 90 CV 449
DENNIS KINNEY and
KAREN A. KOPRAS,
DEFENDANTS,
and, after due advertisement, the subject premises hereinafter described were sold on July
2, 1991, to First National Bank of New Richmond for the sum of $36,930.02.
And, WHEREAS, the said First National Bank of New Richmond is now entitled to
a conveyance according to law,
NOW, THEREFORE, the undersigned in consideration of the payment to him of
$36,930.02, receipt of which is hereby acknowledged, conveys to the First National Bank of
New Richmond, a Wisconsin corporation, the following tract of land in St. Croix County,
Wisconsin:
Part of SW 1/4 of Section 19-30-18 described as follows: commencing on the
E and W 1/4 section line of said Section 19 in centerline of Town Road (said
point being 2143.0 feet E of W 1/4 of said Section 19); thence S29 * 18'W
1067.0 feet to a point on said centerline and Place of Beginning; thence S
29'a 41'W on said centerline 503.4 feet; thence N68D 49'W 89.8 feet; thence
N9 * 21V 198.5 feet; thence N10 " 54'E 214.5 feet; thence S87 o 4TE 325.00
feet to the Place of Beginning.
DATED thisZ��cday of July, 1991. ,,',,�` .� %%'
�;EGISTER'S OFFICt Ralph Bader
m o
ST, CROIX CO., W1 Sheriff, St. Cro my
Reed for Record f�VFD
12
J U L 16 1991L r�
at 11: 40
A. M
j�����
�..,A-,' a e Of Register of Deeds
VOL 9N..?AGE
STATE OF WISCONSIN �
ss.
COUNTY OF ST. CROIX �
On thisv�day of July, 1991, before me came Sheriff Ralph Bader, known to be the
individual and officer described in, and who executed, the above conveyance, and
acknowledged that he executed the same as such Sheriff, for the uses and purposes therein
set forth.
Not bl i c, Ciro&{ Ctoijxty ; :
State of Wisconsin
My Commissior�'�ire r
THIS INSTRUMENT DRAFTED BY:
BAKKE, NORMAN, SCHUMACHER,
SKINNER & WALTER, S.C.
900 Main Street
P.O. Box 54
Baldwin, WI 54002
(715) 6844545
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS:- �4 4JgFIRE NO:
LOCATION: 4 SEC, l q T -N-R W►
TOWN OF: ST* CROIX COUNTY
SUBDIVISION:
LOT NO.
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. C ' roix County residents may be eligible to receive a grant to
help with the cost of the 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 system properly
maintained.
The property owner agrees to submit to the 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 from 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 DNR,
Certification form must be completed and returned to the St.
Croix County Zoning officer within 30 days of the three year
expiration date.
SIGNED:
DATE
St. Croix County Zoning office
911 4th Ste
Hudson, WI 54016
DEPARTMENT OF
REPORT ON SOIL
BORINGS AND
SAFETY& BUILDINGS
INDUSTRY,
DIVISION
LABOR AIqDr
PERCOLATION
TESTS (115)
P.O. BOX 7969
HUMAN RELAT[QjNS
MADISON, WI 53707
* 11�_
/-&�
LHR 83.090) &
Chapter 145)
LOCATION:
SECTION:
/T,30N/R
VWNSH9�14_UNICIPALITY:
OT NO.: BLK. NO.:
SUBDIVISION NAME:
4
(04_
(50—UNTN7
Zee K
j� h
/I /Z lZit" 44,
MAILING ADIDRESS:
'p, z
USE
fC
DATES OBSERVATIONS MADE
A Residence New NO. BEDRMS.: COMMERCIAL DESCRIPTION.
L-W I
PROFILE DESCRIPTIONS: EIRCOLATIR514 TESTS:
Replace
/Z el, — 9 z
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN -GROUND -PRESSURE: TANK: RECOMMENDED SYSTEM: (optional)
S E U S au aS Qu QS ZU QS A
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. I L H R 83.09 15) (b), indicate: 41� Floodplain, indicate Floodplain elevation:
FrROFILE DESCRIPTIONS
BORING
NUMBER
TOTAL
DEPTH IN,
ELEVATION
DEPTH TO GROUNDWATER
-INCHES
EST. HIGHEST--
CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
OBSERVED
B-
B-
B-3
aloo'
L.�A'd
B_
B-
B-
r- 44- PERCOLATION TESTS
TEST
NUMBER
DEPTH
DEPTH
WATER IN HOLE
AFTERSWELLING
TEST TIME
INTERVAL -MIN.
DROP IN WATER LEVEL -IN NES
RATE MINUTES
PER INCH
PERIOD 1
PERIOD 2
PERIOD 3
P-
P_
1
Z;010"
e2
J-i-
P_
P_
P-
he hori-
6rcent
the undersigned, hereby certify _that 7this form were made by me in accord with the procedure's and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are corre
NAME (print): TESTS WERE COMPETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
Ao� CST SIGN :
.T U 9 E
1/511_'�
7 1
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DiLHR-SBD-6395 (R. 10/83) — OVER
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD w 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;
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 scale is prefered. A separate sheet
may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, 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 and place your current address and yur 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")
cob —
Cobble (3 - 10")
gr —
Gravel (under 3")
's —
Sand
cs —
Coarse Sand
med s —
Medium Sand
fs —
Fine Sand
Is—
Loamy Sand
'sl —
Loamy Sand
'1 —
Loam
'sil —
Silt Loam
si —
Slit
cl —
Clay Loam
scl —
Sandy Clay Loam
sicl —
Silty Clay Loam
sc —
Sandy Clay
sic —
Silty Clay
'c —
Clay
pt —
Peat
m —
Muck
Six general soil textures
for liquid waste disposal
TO THE OWNER:
BR —
Bedrock
SS —
Standstone
LS —
Limestone
HGW ---
High Groundwater
Perc --
Precolation Rate
W —
Well
Bldg --
Building
> —
Greater Than
—
Less Than
Bn ----
Brown
BI --
Black
Gy —
Gray
Y —
Yellow
R —
Red
mot --
Mottles
w/ —
with
fff —
few, fine, faint
cc ---
common, coarse
mm —
Many, Medium
d ----
distinct
p —
prominent
HWL —
High water level,
surface water
BM --
Bench Mark
VRP —
Vertical Reference Point
This soil 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 field prior to permit issuance. A complete set of plans for the private sewage system
and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
PLOT PLAN
PROJECT /,WADDRESS z0f_ %F � �. r
60 1/4 1/4/S/f [T10 N/R /1M TOWN COUNTY
y
MPRS Byron Bird Jr. 3318 DATE �--/--- / � .� •
BEDROOM CLASS PERC Z CONVENTIONAL/ IN-GROUN'�'DOO'PRESSURE
CONVENTIONAL LIFT MOUND HOLDING TANK
SEPTIC TANK SIZE LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE -BED SIZE —qO
k Benchmark V.R.P. Assume Elevation 1001
Location of Benchmark f `-`- 5 e
>
H.R.P.�IV
0 Borehole Well Scale Feet
0 Perc Hole System Elevation
I \
(5
41,
L p L
P