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HomeMy WebLinkAbout032-1042-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 538848 0 GENERAL INFORMATION 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: Jaeger, James Somerset, Town of 032-1042-60-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 13 f GST 15.31.19.211B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER sCAPACITY STATION BS HI FS ELEV. Septic eg" / Benchmark / c t ~ ~ Dosing Alt. BM ` Aeration Bldg. Fewer ems- ~l E ~ ~1~. Holding St/Ht Inlet St/Ht Outlet LS TANK SETBACK INFORMATION 7- , 7 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Btt1112P • t 1-.-- /7 ~j Septic Dtt7 #6 39 ~q:%L,.- Header/Man. tp J ' i 75b~ 756 - yS~~ Aeration Dist. Pipe Holding Bot. System 7. C' ` PUMP/SIPHON INFORMATION Final Grade 3• W. Manufacturer Demand St Cover GPM Model Numb TDH Lift Friction Loss System Head H Ft Forcemain Leng o Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 / ~jQ ~ SETBACK SYSTEM TO Z Y P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: -tom ~t•`~~ INFORMATION CHAMBER OR J..ti Type Of 5 ow 'a System: 7/41 09 7 7 AA- UNIT Model Number: i ,c j'/ ~ 4 tn/ DISTRIBUTION SYSTEM 3 Header/Manifold •l) Distribution Ix Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length \ Dia `Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/S dded xx M !;~,Yes Bed/Trench Center Bed/Trench Edges Topsoil Yes No No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2156 60th Street Somerset, WI /5025 (SE 1/4 NE 1/4 15 T31 `N R1 9W) NA Lot 1 Parcel No: 1 1.19.211 B 1.) Alt BM Description = 5e~~, vaJ ems. 7 i•C G~JL~,, ~"a G 2.) Bldg sewer length = - amount of cover = G 3 ~i, Imo- V a'~tJ~• a /1. SYGf/ revision Required? Yes No CZ% it tier side for additional information7 (R.3/97) Date Insepcto s ignature Cert. No. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 538848 0 GENERAL INFORMATION 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: Jaeger, James Somerset, Town of 032-1042-60-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 15.31.19.211 B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Tot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded jxx Mulched Bed/Trench Center Bed/Trench Edges Topsoil 0 Yes 7a No N Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2156 60th Street Somerset, WI 54025 (SE 1/4 NE 1/4 15 T31 N R1 9W) NA Lot 1 Parcel No: 15.31.19.211 B 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Ful Yes No Use other side for additional information. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) Commerc e.wl.gov Safety and Buildings Division Conn 201 W. Washington Ave., Y.O. Box 7162 Cf~ i scons i n Madison, Wl 53707-7162 Sanitary Permit Numberr ((tto ~e filled in by Co.) F4 1 1]epartment of Commerce U g C~_ Sanitary Permit Applicatio State Transaction Number - In accordance with s_ Comm. 83.21(2), Wis. Adm. Code, submission of this form t a le govemate l unit is required prior to obtaining a sanitary permit. Note: Application forms st wn TS are Project Address (if different han mailing address) submitted to the Department of Commerce. Personal information you provide may be sed seep _purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats_ I. Application Information - Please Print All Infor ion Property Owner's Name / ^ e I"C ^ 4s 1~ H G L,► Parcel # J moo- 6 oZrU Property Owner's Mailing Address Property Location / C~/ t7 -,,)A ST C Govt. Lot _ City, state Zip Code 6 OFFICE SC ''/s, A),JE-_' O~Q/5P ) selon~ lAye on,~~~~ T_N; R EtfrWJ II. ype of Building (check all that apply) ~ Lot # 1 or 2 Family Dwelling - Number of ooms I Subdivision Name Block # ❑ Public/Commercial - Describe Use ❑ City of'._ _ ❑ State Owned - Describe Use CSM Number t El illage of Z G~c►«~l oe own of ~ i1tQ / A Q5 N III. Type of Permit: (Check only one b x on line A. Complete line B if applic t ) A' ❑ New System Replacement System ❑ Treatment /Holding Tank Replacement Only ❑ Other Modification to Exis ing System (explain) 11• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Numbyr i nd Pate Issued Before Expiration Owner I IV. TVpe of POWTS S stem/Com onent/Device: Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound >24 in. of suitable soil L1 Mound < 24 in. f suitabllee~soiI LQ °t ❑ Holding Tank ❑ Other Dispersal Component (explain) _ ❑ Pretreatment Device (explain)--37t~~~,R,( L! 1 t6 CA 4 V. Dispersal/Treatment Area Information: es c~ Design Flow (gpd) Design Soil Application Rate(grp D ispersal Area Require sf) Dispersal Area Proposed (st) ys em Eler ation VI. Tank Info Capacity in Total # of Manufacturer , Gallons Gallons Units New Tanks Existing Tanks e 0 rn w C7 w Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- L the undersigned, assum nsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ` e MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) ~Vnl VII oun /De artment Use Only Approv roved Permit 75- FeeeDate l sued / I'ssuin ent Signature iven Reaso vial $ ! UL Condi Reasons for Disapproval Q L~ t i4 "Septic tank, tlfluent filter and tJ .dispersal ceN must all be services I maintained as per managemerit plan provided by plumber. 7- Aid suck refit ements must, be maintained Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches in size SBD-6398 (R. 02/09) PLOT PLAN PROJECT James Jaeaer ADDRESS 2156 60th St. Somerset Wi 54025 SE 1/4 NE 1/4S 15 /T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 9/20/11 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 32 BENCHMARK V.R.P. Top of manhole cover ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark Well is to meet all SYSTEM ELEVATION 93.6' 4.5' below qrade C B-1 setbacks required by WDNR Well Scale is 1" = 40' Property Line 35' unless otherwise Plans Designed Using Pro 3 noted Conventional Powts Bedroom 5' Manual Version 2.0 house 20' riveway 30' Vent >6" Quick4 Standard-W T of Cover Leaching Chamber with 20.0 ft2 of Area 15' 4' Long 5.8ft^2/pair of end caps 12" B-1 44 20' 3 477 Grade at System Elevation Valve Huffcutt filter tank Driveway 65' 12' X 50' bed 150' B-2 7' Vent 1-3' X 130' cell 1% slope 5' 250' 5' B-3 Vent' 60th St. Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 Date: 9/20/11 Owner: James Jaeger Location: SE1/4 NE1/4 S15 T31 N,R19W 2156 60th St. Somerset System type: In-ground absorbtion system (conventional) Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-5. Maintanance and Contingency Plan 6. Filter Specifications Sheet 7. Utilization of existing septic tank f ~r Signature License number #22 PLOT PLAN PROJECT James Jaeaer ADDRESS 2156 60th St. Somerset Wi 54025 SE 1/4 NE 1/4S 15 /T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 9/20/11 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 32 BENCHMARK V.R.P. Top of manhole cover ASSUME ELEVATION 100° Filter BEST Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark Well is to meet all SYSTEM ELEVATION 93.6' 4.5' below grade @ B-1 setbacks required by WDNR Well Scale is 1" = 40' Property Line 35' unless otherwise Plans Designed Using Pro 3 noted Conventional Powts Bedroom 5' Manual Version 2.0 house 20' riveway 30 Vent >6" Quick4 Standard-W of Cover Leaching Chamber T with 20.0 ft2 of Area 5.8ft^2/pair of end caps 15' 12" 4' Long B- 20' 3 4„ Grade at System Elevation Valve Huffcutt filter tank Driveway 65 12' X 50' bed 150' B-2 7' Vent 1-3'X 130' cell 1% slope 250' 5 B-3 Vent 60th St. Cross Section of Quick 4 Standard-W Leaching Chamber Typical cross section for 1 of 1 cells Intial Grade Elevation Quick 4 Standard To be >1' above grade Leaching -.Chamber 98'1 with 20.0 fft2 of Area per Chamber 10. lft^2 pair of Finish grade elevation end plates ag 1' Typical Installation Lvent Grade /34 From Se ptic Tank L34Grade at System Elevation 1-3' X 130' Cell Same on other end Observation tubeNent Located at end of cell A 32 chambers per cell System elevations: A-93.6' Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Eff luent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. If system fails, determine cause of failure, use alternate area and install new r'Mtested replacement area. Option #2. nstall system at a lower elevation, by removing chambers, removing biomat, and ' all new system./emu /-V olj'sezUA--~ Option#3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715-246-4516 St. Croix County Zoning 715-386-4680 Pumper Tom Mondor 715-246-5148 Shaun Bird #226900 lop~ ~ daa (LDL cn U. CD p I a i-- I+' " ~ ~jlCll~ I .p y N r~ _ -to - - Vl ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK 11.111.s is to certify that I have inspected the septic tank presently serving the ' _ residence located at: .S~%Section, T _N, R_/ 7 W, Town r)f .S~ac~Qt Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. i._,ast time serviced: oid flow back occur from absorption system? Yes _ No (If no, skip next line) Approximate volume or length of time: gallons minutes :'rapacity: /00-0 Construction: Prefab Concrete Steel Other Manufacturer: (If known): Age of T (If known) ( ' nature) (Name) Please print (Title) (License Number) Date Dorm to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wi dm. Code (except for inspection opening over outlet baffle). Name/ r Signature MPJMPRS ~61?V ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J A,.,, 4 e o.,3e/ Mailing Address a1 c~ 42 5 J1~ In1s2 (,c~a J~~~d Property Address ~7 2. (Verification required from Planning & Zoning Department for new construction.) 11 3 City/State Parcel Identification Number. LEGAL DESCRIPTION Property Location SE '14,146 '/a , Sea , T N RW, Town off' Subdivision , Lot # y O(~ , Volume , Page # Certified Survey Map # Warranty Deed # ( Volume Page # J Spec house yes o Lot lines identifiabl ye no SYSTEM 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. I/we, 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. Nu er of bedrooms SIGNA O APPLICANT(S) DATE 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) D Wisconsin Department of Commerce L EVA REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. e t~ County n ` Attach complete site plan on paper not less than 81/2 x 11 inches ~'~q I. roust l r include, but not limited to: vertical and horizontal reference pg0po ~clion and Parcel I.D. rest road. o3a 6~r percent slope, scale or dimensions, north arrow, and location and distance 06 Please print all information.Crn 21 Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy Law ~3~ "(0) Property Owner Z tfil Location ~tp,NNtNG & 32--p- Govt. Lot S~ 1/4/L51/4 rT j~ N R E (or (W Property Owner's Mailing Address Lot Block # Subd. Name CSM# ~5~ 6 1- city State Zip Code Phone Number ❑ City ❑ Village Town Nearest Ro d ❑ New Construction Use• esidential /Number of bedrooms Code derived design flow rate ~SV GPD replacement ❑ Public or commercial - Describe: Parent material b Flood Plain elevation if applicable ft. General comments and reconuriendations: System Type L~~ System Elevation 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. 'Eff#1 'Eff#2 c 3 1 Boring # RBoring ~~ftJ/) pit Ground surface elev. / . Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 , U 14S, g~l v 3 y s S ~V i~ Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 nxjf/ ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 5401 715-246-4516 Property Owner Parcel ID # Page of ®Boring # Boring pit Ground surface elev. ft: Depth to limiting factor LL-= 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. 'Eff#1 •Eff#2 2 - S l 1t F-1 Boring # 0 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. `Eff#1 'Eff#2 a Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor in. 11 - Soil Application Rate Horizon ' )epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BODE > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' Effluent #2 = BODS 130 mg/L and TSS 5 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. SBD4330 (8.6/00) Soil Test Plot Pla Project Name James Jaeger Sh Bird Address 2156 60th St. Somerset Wi 54025 M #226900 Lot 1 Subdivision Dat 9/20/11 SE 1/4 NE 1/4S 15 T 31 N/R19 W Township Somerset Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of manhole cover System Elevation *HRPSame as Benchmark Well Scale is 1" = 40' Property Line 35' unless otherwise Pro 3 noted Bedroom 5' house 20' riveway 30' T 15' B-1 20' Driveway 65' 12' X 50' bed 150' B-2 Vent 1% slope 65' 250' B-3 60th St. 0 PI IL P 427237 JUN 221987 CERTIFIED SURVEY MAP Located in the SE1/4 of the NE1/4 of Section 15, T3IN,R19W, Town of Somerset, St CroiX County, Wisconsin. NOTE: This CSM is Surveyed for: Bill Sommerfeldt hereby created to correct and Rt. 2 Box 158 replace those CSM's recorded in New Richmond. Vol 5, Pg. 1372, and Vol. 61 Pg. 1537. NE CORNER APPROVED TE3I NI~R I9 W JUN 12 1987 _UNPLATTED_ LANDS _ 0 0 I ST. GROIN Cf: UNITY N Hg~ 38' S5" E 550.00' 33' 33'! COMPREHENSIVE PARKS PLANNNVO AND ZONING COMMII'M Vh 58.8H 3SH.12 2 \ 2 n 158.88' _T 1-I W II z LOT 1 I = cI 136821 S Q. FT. ( 3.60 ACRES) 4M, 3 EXCLUDING RIGHT-OF-WAY ; I+ o I N 184981 SQ. FT. (4.25 ACRES) M 2 3 z al o INCLUDING RIGHT-OF-WAY o a z Z I ~ ~ ~ ¢ W I/4 CORNER ' W 156.89' 354.12' E I/4 CORNER 8 890 381'55°W 550.00' 3 EAST-WEST i/4 SECTION f[ LINE UNPLATTED LANDS OI w 3 TOWN ROAD NON-EXCLUSIVE ACCESS EASEMENT H W ~ W 2 LEGEND xo I" 150' o 3 SECTION CORNER MONUMENT SCALE IN FEET ~n • O' 75' 150' 300' W I" IRON PIPE FOUND Z W O W 2 M I"X 24" ROUND IRON PIPE WEIGHING 1.68LBS/LIN. FT. SET. ~oN ZW A parcel of land located in the SE 1 /4 of the NE 1 /4 of Section 15, WA T31N, R19W, Town of Somerset, St. Croix County, Wisconsin, described ad W~H as follows: Beginning at the El/4 corner of said Section 15, thence S89038'55"W along the East-West 1 /4 section line (bearings referenced to the East-West 1/4 section line of said Section 15, assumed S89°38'55"W) 550.00'; thence N 1°0 1' 32 "W 336.35'; thence N89°38'55 "E 550.00' to the East line of the NE 1 /4; thence S1'01'32"E 336.35' along said East line to the point of beginning, containing 184,981 square feet, (4.25 acres) more or less, and being subject to town road right-of-way as shown and all other easements, restrictions and covenants of record. I, Harvey C. Johnson, registered Wisconsin Land Surveyor, do hereby certify that I have surveyed and mapped the above described property; that such plat is a true and correct representation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Section 236.34 of the Wisconsin Statutes, the St. Croix County Subdivision Ordinance, and the Town of Somerset Subdivision Ordinance to the best of my prof ►9VI!iNM~Aowledge, understanding and belief. G~GC)IV i Harvey G. Johnson Wisconsin Land Surveyor S-1899 HSAR E G. Rusch Surveying Inc. z 407 Second Street 1 Hudson, Wisconsin 54016 ~6! ~J 6_7 June 10, 1987 <.qrv 487-1252 Vol. 7 Pg. 1839 y~~h #se s N,~~~ 10 1 *36 STATE BAR OF WISCONSIN FORM 2 - 1999 ~~SS4 i:A , NL F_:_N H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Darvin L. Dodge and Gloria E. Dodge, RECEIVED FOR RECORD husband and wife, 02-20-2001 3:00 PM WARRANTY DEED Grantor, and James K. Jaeger and Melanie Jaeger, husband and EXEMPT II CERT.GOPY FEE: wife, - COPY FEE: - TRANSFER FEE: 504.00 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Part of SE 1/4 of NE 1/4 of Section 15-31-19 described as follows: Lot 1 of Name and Return Address Certified Survey Map filed June 22, 1987, in Vol. 7, page 1839, Doc. No. Lawson, Marshall, McDonald 427237, St. Croix County, Wisconsin. & Galowitz, P.A. 3880 Laverne Avenue North Lake Elmo, MN 55042 032-1042-60 Parcel Identification Number (PIN) This --is homestead property. (is) MX00 Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of - February 2001 - - - - * Dar?/In L. Dod a + Gloria E. Dodge _ AUTHENTICATION ACKNOWLEDGMENT Signature(s) Darvin L. Dodge and Gloria E. Dodge, husband STATE OF WISCONSIN ) and wife, ) ss. County ) authenticated this day of February 2001 Personally came before me this day of / ( the above named • Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) - THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland _ Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is pennanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) - - Names of persons signing in an capacity must be typed or printed below their signature. information Profmsicnals company. Fond du Lac. Vv1 any 800-e55-2021 STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2- 1999 0 to 0 3 -0 0 d r1 m c ro O N 3 O lD OD Cp YH j C' m z a y O CD oj CD t,) F3 d 00 y v - CD 1 O-0 0 0 CD (D p ..a O ~O1 3 m r2 ! °o o' I ~ (n ~ D CD o, 0) O V CD (D y Cn d .+O c CD c CA) CD .0. W CODS ! ~~1 CL N co CO 0 n r N 00 N Ul ccno 3 3 M z 0 0 0~ I • O g K (a ca (A c~ o ~D "(may CT T O O o o CD v N 3 OD CL .r CO Z Z -I Z O 0 D m 7 "m~ • Cl) CD fD N C W D Z CD cb -1 CA O, in O A Z f~'! J ` M C 0 0. W CT1 m T m a CD z c 3 c z - m CO M z m ? 0 CL N ~ ch 0 CCDD O d III COD I ° C0 0 c I N Q y CD 00 d 0 CD CD CD N 0 CD 0 y 3 u, U) D °o° w 1 7 rl) CD CCDD N O A CL 03x ba CD N 00 S a CD D0 V 49 0 ti O 4~ ~ a O 0. Parcel 032-1042-60-000 04/25/2006 08:35 AM PAGE 1 OF 1 Alt. Parcel M 15.31.19.211 B 032 - TOWN OF SOMERSET Current ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - JAEGER, JAMES K & MELANIE JAMES K & MELANIE JAEGER 2156 60TH ST SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2156 60TH ST SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 4.250 Plat: N/A-NOT AVAILABLE SEC 15 T31 N R1 9W 4.25AC SE NE LOT 1 CSM Block/Condo Bldg: 7/1839 REPLACES CSM 5/1372 & 6/1537 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-31N-19W Notes: Parcel History: Date Doc # Vol/Page Type 02/20/2001 638884 1589/304 WD 07/23/1997 711/228 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.250 54,200 113,000 167,200 NO Totals for 2006: General Property 4.250 54,200 113,000 167,200 Woodland 0.000 0 0 Totals for 2005: General Property 4.250 54,200 113,000 167,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 105 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 n221911 42 I% CERTIFIED SURVEY MAP Located in the SE 1 /4 of the NE 1 /4 of Section 15, T 31N, R 19W, Town of Somerset, St Croix County, Wisconsin. NOTE: This CSM is Surveyed for: Bill Sommerfeldt hereby created to correct and Rt. 2 Box 158 replace those CSM's recorded in New Richmond. Vol 5, Pg. 1372, and Vol. 6, Pg. 1537. NE CORNER SECTION 15 ~0 ~ ~ _ s l s,, ! 'f 01 T 31 N, R 19 W UN 12 UNPLATTE D_ LANDS _ o 0 S1. CO!X 1.:,•IJ'I~`F 9 33' 33' N+ COMARE;icNSM~" PAI:t:J 'IANP41(40 N 890 38' 55" E 550.00' v n AND ZONING COMMITI'E► 158.88 358.12 N1 ~ ~ 41- - - Zi 0 158.88' 358.12' ~1 w Q / I WI z Ji LOT I~ W:I w x WI _ 156821 SO. FT. ( 3.60 ACRES) v~1jI ~ ~ a EXCLUDING RIGHT-OF-WAY 3 N " 0 QI 0 184981 SO. FT. (4.25 ACRES) e 3 I z JI INCLUDING RIGHT-OF-WAY o o M In -J n' o M - 1 o r- z z o l w W I/4 CORNER I Z OIL 158.88' 358.12' I E1/4 CORNER S 890 38''55"W 550.00' 133 EAST-WEST 1/4 SECTION 'I LINE UNPLATTED LANDS 01 w 3 *TOWN ROAD NON-EXCLUSIVE ACCESS EASEMENT e~ W wz =o LEGEND SECTION CORNER MONUMENT SCALE IN FEET 1" = Iso' oN3 I IEEE= O IL N 0' 75' 150' 300' .0- I" IRON PIPE FOUND zwco K?0 -e- I " X 24" ROUND IRON PIPE WEIGHING WZp1 m 1.68LBS/LIN.FT. SET. ~oN A parcel of land located in the SE 1/4 of the NE1 /4 of Section 15, K N T3 IN, R19W, Town of Somerset, St. Croix County, Wisconsin, described WAN as follows: Beginning at the E1 /4 corner of said Section 15, thence m S89°38'55"W along the East-West 1/4 section line (bearings referenced to the East-West 1/4 section line of said Section 15, assumed S89°38'55"W) 550.00'; thence N 1001' 32"W 336.35'; thence N89°38'55"E 550.00' to the East line of the NE 1 /4; thence S1°01'32"E 336.35' along said East line to the point of beginning, containing 184,981 square feet, (4.25 acres) more or less, and being subject to town road ..tom -r - I----' -"--3 -l7 _,1_--" __..-__-_L.. --A ..+o _ t., A- Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER"L TOWNSHIP 5ft6k-t SFaa SEC. T N-R W ADDRESS St, E~~ , ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ti f f ~Aa a~f INDICATE NORTH ARROW DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUILDING,< P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound ui assigned) NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: Daryin Dodge R. R. INS EC ION DATE Somerset, W1 _3 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: JA d SE NE, Section 15, T31N-R19W, Town of Somerset, Lot#1 REF. PT. ELEV.: CST REF. PT. ELEV. Name of Plumber MP/MPRSW No- County: Gary L. Steel 3254 Sanitary Permit Number St. Croix 64886 SEPTIC TANK/HOLDING TANK: MANUFACTURER: C/~ a LIQUID CAPACITY: TAN INLET ELEV. TANK OUTLET ELEV.: WARNING LABEL ffq' !J / LOCKIN COV R VVv L/%4 1l~ P OV ED: PROVI D: BEDDING: VENT IA. VEpIT qTL.. HIGH WATER EC," YES ON NO C` ALARM. NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH DYES ONO FEET FROM C LINE, AIR INLET OYES ONO NEAREST Q DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER DYES ONO PROVIDED: PROVIDED: GALLONS PER CYCLE: PUMP AND CONrROLSOPERATIONAL DYES ONO OYES ONO (DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL BUILDING VENT FRESH PUMP ON AND OFF) FEET FROM LINE' AIR INLET : ❑ YES ❑ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NO NEAREST or excavation. (If soil can be rolled into a wire, constructions all cease until FORCE uIAMErER' MATERIAL AND MARKING the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF BED/TRENCH DISTR PIPE SPACING. COVER #PITS DIMENSIONS / TREN HES I ~ M AL: INSIDE CIA LIQUID PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR PIP DISTR. PIPE MATERIAL: NO. BELOW PIPES. ABOVE COVER. EL s. IN ET. j `N ^ Z NUMBER OF PROPERTY WELL. BUILDING VENT TO FRESH 5 PIP FEET FROM LINE ^ AIR INLET: NEAREST->♦ U MOUND SYSTEM: Mound site plowed perpendicular to slope and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS: DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED OYES ONO DYES ONO CENTER EDGES: DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED: OYES ONO OYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. DIMENSIONS TRENCHES: FILL DEPTH ABOVE COVER MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV. ELEV. DIA. ELEV. PIPES DIA.: [DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: COMMENTS: DYES ONO OYES NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: DYES ❑Nlp FEET FROM LINE: DYES ONO NEAREST S -1o Sketch System on Reverse Side. Re in in county file for audit. SIGNATU TITLE: DILHR SBD 6710 (R. 01/82) L-~ ? wlsconsln APPLICATION FOR SANITARY PERMIT X71 L H R COUNTY (PLB 67) UNIFORM SANITARY PERMIT # ~ OEPRRTTEnT OF / ~y ~ InousTRV,LRBOR&MUMRnRELRTIOns -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 PR INNER MAILING ADDRESS 2s PROPERTY LOCATION C +W: VW I ASE: 1/4 /')C1/4, S 5 , T.3/, N, R E (Or) W TOWN OF: C~-!»~an S LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST AD LAKE OR LANDMARK STATE PLAN I.D. NUMBER / do . I cam- - - r~ A2 a r7 TYPE OF BUILDING OR USE SERVED d c~~ - ~Q~aZ ~a~ao 54 1 or 2 Family Number of Bedrooms. Z Public (Specify): THIS PERMIT IS FOR A: 2S New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed S.Seepage Trench ❑ Seepage Pit ❑ Holding Tank 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: A IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. ie Steel Fiberglass Plastic Gallons Tanks Concrete ConSsttructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): .r& S_ Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. PRSW No.: Phone Number: 4MRIM Name o lumber (Print): ISignat I<f Plum er's Ad ess: Name of Designer: W, 'J - 41, i COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ' ❑ Owner Given Initial ~ ~9Approved Adverse Determination Reason for 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/contractpr,,("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 ~U2 Location of Property-S.6- 34 N6' 4, Section ) 5 , T -31 N - R W Township scyy, Mailing Address _Ira Subdivision Name Lot Number T - Previous Owner of Property ~3'Y2 Total Size of Parcel z2go:1,4s Date Parcel was Created y 'rJ -,8 S Are all corners and lot lines identifiable? 41--~-Yes No Is this property being developed for resale (spec house) ? Yes No Volume 7`/ and Page Number Z Z & 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. PROPERTY OWNER CERTIFICATION I (We) ceati.6y that aU e.tatemente on .thi6 6onm ane tAue to the but o6 my (ouA) h.now.eedge; that 1 (we) am (ahe) the owneh (a) o6 the pnopen ty dedcAl.bed in thi,6 injoAma ion JoAm, by viAttu.e of a waAnanty deed Aeconded in the 066ice o6 the County RegiAteA o6 Deedb aA Document No. 5/p z and that I (we) ii DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 01629 V0,- 711 PAGE `.19-TF REGISMS OFFICE Bank.- of New_• Richmond a__ ul ST. CROIX CU. WIS ...y..-or_ anized_ and ex d ting_-s ate.__ ark ng__Gorpor_at< on.......... Rec'd. for Record this 1st day of May A.D. 9 • . conveys and warrants to ..D~arvin...D.O.dg.e..dnd..Glor.i&..Do.dge".. lot 8:30 A husband..and.-Sri-fe--as... jo-int --tenant,.s•-.--•--------------------------- a~ - 1111 . ::-.c. _ , . i RETURN TO ii . . the following described real estate in .St. Croix County, State of Wisconsin: Tax Parcel No: Lot 1 of Certified Survey Map recorded in Vol 1 f Certified Survey Maps, page 1372, Document No. 389372, located i e Southeast Quarter of the Northeast Quarter (SEk of N54) of Section Fifteen (15), Township Thirty-one (31) North, of Range Nineteen (19) West, St. Croix County, Wisconsin, together with the following described parcel adjoining said Lot 1: CcMencing at the East quarter corner of said Section Fifteen (15); thence South 890 38' 55" West (assumed bearing referenced to the East-West quarter section line of said Section Fifteen (15), 391.12 feet along said line to the Point of Beginning; thence continuing South 890 ' 38' 55" West, 158.88 feet along said line; thence North 1 01 3211 West, 336.35 feet; thence North 890 38' 55" East, 158.88 feet; thence South 10 01' 32" East, 336.35 feet along the West line of said Lot 1 to the Point of Beginning, and being subject to all easements, restrictions and covenants of record, including the future town road right of way referenced in said Certified Survey Map. This TR,ANSFM ?.$.._xl0k.......... homestead property. $ , O (is) (is not) Exception to warranties: F Dated this 2.9 tll April day of BANK OF N C " (SEAL) B.. (SEAL) . Richard Schurtz.,..-Pre gifent (SEA (SEAL) + ames_. Gretz... e-Pre _don_t AUTHENTICATION ACKNOWLEDGEMENT Signature (a) STATE OF WISCONSIN ss. y----•---------•---•--•• St. Croix •-•---------••------------County. authenticated this ........da of 19 2 9th le~sonally came before me this ........day of Apr H 9 STC - 105 r SEPTIC TANK MAINTENANCE AGREEMENT rH+ St. Croix County t7 O W N E R F'a=R~ 1 t7 _ H rh ROUTE/BOX NUMBER Fire Number CITY/STATE M/ =IIP OZ-5 PROPERTY LOCATION:5 ~4, jL E 14, Section `~j T 31 N, R___-W, I Town of ~Q7n CeL S @J- St. Croix County, Subdivision 4J Lot number I Improper use and 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 0 I/WE, the undersigned, have read the above requirements and agree v~ to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the-St. Croix County `honing Office within 30 days of the three year expiration date. SIGNED, s-- DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and retufii to above address. N w Dl ~ ~ ;jam i. TY.:tr... C O p O d w C e N N N~ N rn O C0'-V U O C p O i dl C Ql ' _V 'm C7 yLt a~ O ` O m C o v C73~ 0 W o e~'ov M'M ai 3 ov 3 pa v E c ~ O c Olm:~ `N 1 ~q n c may.. mca N N G V N O N' 0 W cc f-c4) c 0CccNVai %a)- o 0 ; o e~ N tmo ot't'+L ~r eov ~ y ~~L~. 0 m Q U 0 :E a) 4) E a cc - L. 4) Cc LL 3t 4i ca U (0 = y Q cm N ; N (.0 dL C 0)~ o ; O ; O'0 0 0 R1 ; to C U U O- V o ` O O a ~Q y 0)> U' CL C). OD CC C c a~*0 o, o (1) C o c - « w C O O O i (d O O'0 0 E 30 p>Z'C C C L cc O O (a O C C _Y cvi 0) 0 CD N O o i O i 0) 0) .t. C^ ) w V d C arD, Cc(DAC4) m34~i m C (D O, U C O CI> Q cif 3: U) of O y y d N 0 0 C CD C p 0) 01 E C 2 (a>, ~(u(u`Od 0.0 a iii rnY o m 3 c co>,>>a~c 3 m m {~l.J O E CM 2 W co c CZ I ~ J N O DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND" PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN FiELAT10NS \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: SHIP/*bf+6FMLITY: LOT NO.:: SUBDIVISION NAME: t t~ / N/RI~A(or) WTOWNSa-M &-e s C:4- BLK. . NO. NO. COU T : O NER'S/t3t!`YWS NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER LAT ON TESTS: ®Residence rf New ❑Replace L f RATING: S= Site suitable for system U= Site unsuitable for system j `i CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®,S ❑U &S 0U , 0S DU El S Z U ❑ S alu [under Percolation Tests are NOT required DESIGN RATE: [Floodplain, any portion of the tested area is in the s.H63.09(5)(b), indicate: indicate Floodplain elevation: /IIA 1 PROFILE DESCRIPTIONS O (IDA Z BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITA5 ax- H THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTtM, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) z p B- 7 HONG ;>l~ I Cr) .ol' 'J91 'S_49.71 AH 1. B-3 8 7~q /Lb roc '-8 it 2- 8 .s,c.. s ~u on a B- 107 0 4 A) F_ (P ? (o I ~7_ r S. L . . S_ ~J '?13n - r✓° . S . B- ~qz (nom Xba~ ~~4Z %S.x s, D~Sor►1~1 t PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER R+eHf-S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIO PER INCH P- D N C' 3/ .3y~- 3YL P_ ©NC .3 Co <3 P- 3 oau E ,3 G 3 P__ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil Was. 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 j k IF k F. 0 ~o► j i- YL"'fl 10, F - _ 1 s 3 E 1 i I e__- 1 F r E E E E - 3 F 3 I SEYt !UL fq S. l -:31 v . 19 C). StunLrsC-4, -~6consh.P C~, 16~ lv ~I tit e x 04 13.3 q7 rZo C. t< P~E)L 93 j~ f qt9~vx . z--s e-/ /YI p~su~ 3a