HomeMy WebLinkAbout004-1006-40-000 (2)
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~DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUeFR'Y, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION. N/R ~ (or) ~ TOWNSH~/MU CIPALITY: LOT NO.: BLK. N/O.: SUB/DIVISION NAME:
S ZA A) A
M QG~DDRESS:
COUNTY: O NER' BUYER'S NAME: i~*
O ..11o7 a CHaSS~
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIALDESCRIPTION : (PROFILE 1DESCRIPTIONS: PE O ATIONTESTS:
❑Residence ]New L_fFieplace Il T r~6
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑sD ❑sa ❑s asDT Ds au
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(5)(b), indicate: /1//j Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- &_'3/ Sr/ Ts 9" <l & / d erg + g 7 a f
4 C7lFl `e. /D' 44.., 6 C L vn 3 o f jt.
&I TS 7„~~8•. Sr ~ `heir o~je`11 n"~
B- r r l/ f Si l% 3,1 ,P / o
V y••~B/.~,'/1S&'Q 5~l "j~~~ ~^.s'`{Or 9"B~ S.'/ /C~ +r`9o/
B- „ S`- 91° firs 7 lyef Err Q SL p B if
-7 " 6r
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATPER INCH ES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 11 PERIOD2 PERIOD 3
P-
P-
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION m
I € ~ F /
i( P P r c, le- ~ GZ e
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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 (p t): ( TESTS WERE COMPLETED ON:
f hit ~~IE1 rSav~
AD ESS: I CERTIFICATION NUMB PONE NUMBER (optional):
0L4 09 7k
CST SIG, URE:
100,
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
Q }
INSTRUC 'EONS FOB "PLET" FORM 115 - SRO - 6595
To be -impl=ate an(: >r soil )0I incl.ade:
1. CJr ':a! d
- 2. The use section MU- :f I 'rldicate - this is are._sid=ence or c, :.7ject;
3. MAXIMUM numb(-, ,;Dorris or c rcial use Pla n<ad;
4. 1s this a ncv,, c - rr rat sy stern;
S. Complete th:c sui i~ ng boxes. A ;Tfn IS SU1- OR . C TANK ONLY IF ALL
DTHE R SYS: _ P, RULED OUT BASED CAN SCSI ONDITION 3
6- PLEASE use .ons shov"11 here for v"i'iting profile descriptions and completing 'the plot plan;
7. MAKE A t di< i ccurately locating you" test locations. Drawing to scale is preferred. A
scit~arate staf.~~ rt, a>< .a ,sired;
R. Make stare yow bent hniai k nd vertical elevation i nce point are clearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, ca&ressca, flood plain data, percolation test exemp-
tion, if appropriate;
10, if tfae information (such as fs`ao€.1 ;-vatio a) does r-t the appiopi-iat:e box;
11. Sign the 'form and place your s ai,.d your cr ifi a rain
12. Make legible copies and distribi ` requh d. ALL SOIL TESTS ',1UST BE FILED VVITH THE
LOCAL AUTHORITY WITHIN :30 GAYS OF COMPLETION.
RRREr. IONS FOR CERTIFIED SOIL TESTERS
Soil Separates and _ es Other Sy DIs
st Stone. (over, 10„) R ["edr
cob Cobble (3. 10") SS - S<e
r3' Gi t (under 3") LS - L
< 11GVV H >~es
c~ - 'gild P. rc - l' ie
fs _ F3C1c~ {
C#
v ~
Ul-
t ,
.,c, Y -
cry` L~-rra R - R
sic" L; am treat - MC
sir - Silty Clay fff - few, tint, f,~i :t
'c Clay cc c:oi,Ttrxzor i
pt feat n)rrt Man , 2
M - Mock d distinct
p prorrri,-;.....
' Iis.'IL High
~JIrX , •r~F i ~ C)fl t ftu:i 1`
v
ton>~~11 d spr>saE L3fa1 - 1 _
a
eiprice, Point
VR
TO THE OWNER:
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.
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