Loading...
HomeMy WebLinkAbout018-1036-60-300 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552331 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, S.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Will, John W. & Jeanne Hammond, Town of 018-1036-60-300 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: c10 e GI f 0P it /,52 16.29.17.256C TANK INFORMATION ELEV ION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Alt. BM,_ f N~ T ~_te r' %rf Y Aeration Bldg. Sewer / n I.' V j- X _ Holding StAO Inlet St/Ht Outlet TANK SETBACK INFORMATION`- TANK TO P/L WELL BLDG. Vent to Air Intake ROAD ` Sly' ~T r ry Septic n stiff( D (vfi 7. peog- Gt 7 Header/Man. Vac_ GL` (.ti 16,/6 i6l 7-1 Aeration Dist. Pipe , 2 4 ` Holding Bot. System Ot(e, vv t- 5 X3,0 Y7, PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand ver GPM Model Number TDH Lift Friction Loss System TDH Ft Forcemain Len Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING, Manufacturer: INFORMATION CHAMBER-O{2 Typ tOf System: f A/ j r r `UNIT Model Number: DISTRIBUTION SYSTEM IYLa lti ?t "C 1-f Ll 0 C l ./U,1 r 2- i's'1 -v r ad anifold Aion x Hole Size x Hole Spacing Vent to it Intake _t; 4'k < / r TL ipe(s) 1 t l( 11 ~7 Iwo C c. ~~"~7+ l c Length Dia ength Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of eded/Sodded T Mulched Bed/Trench Center Bed/Trench Edges Topsoil xx Se Yes 0 No 0 Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: T / ~e 2' Inspection #2: Location: 906 Cty. Rd. T Hammond, WI 54015 (SE 1/4 SE 1/4 16 T29N R17W) NA Lot 6 ~C Parcel No: 16.29.17.2560 1.) Alt BM Description = 4~t # I t lL'A,./ 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes /No Use other side for additional information. j E j21 GG~ vt v- l0 SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. SO/I 2 ci~U G P ~ ~ - EXi~~ing ~-~a/c E lEv ca, e c / 5/0 .Pei ~.u87 "oAn~Jea~ille Ki,'ll COPY 90(, 0 /a~ G CSC ilo% lQ /7 T. off' ~•r+mo~! of--oVcr kJ'A~ e (c c. ~i a EL', Est~i1~i S bed~com We-JI S~ -"[bfAl yaf';~fr~ctog,_ a P = Cfsm, o ®q3 EXisfa' ~Lb yon O S~d:~q. 1~5su/l7ct~e LJ,-/ .LOS ~o~~ a-~ . V r1 t zc/o o ~'ou-~ /L'~ ~~~y (dk szs F~ l~a.r- ~9G.o9' o = ~ ro"(6,d,=91.z~.~ EXiS~" /~.XS2'~/,;5~'e~'Sa( ~z.o'cor,vto~cr c.~✓/. ~~/fik.uvF ~s w-Fa ce F. (~e,r Ta~IE I C rev- = 81. sa 9 301 l~~a•►l~ 3 ~c~0/ace.rl~r/~ ~ ~9.1•J~' j, r 9%.ZT"` j diSra[~3a-~ ~ ~ o / Cc!/ .-ec , 8 , treys O-~ 9 ~aarnt~r 7~1 County Safety and Buildings Division C Q r~t1 20. W. Washington Ave., P.O. Box 7 Sitary Permit Number (to be fil ed in by Co.) ~ ;kl Madison, WI 53707-7162 s5z 33 1 'z~YlONA4 ta~~r a. ermit Application State Tran ,iron Number In accordance with SPS 383. %is. Adm. Code, submission of this forth to the appropriate governmental unit t A is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m), Stats. I. Application Information - Please Print All Information Property Owner's Name Parcel # 018-1036-60-300 John & Jeanne Will Z C Property Owner's Mailing Address Property Location 906 Co. Rd. T Govt. Lot Hammond Wi jhptWe 5401 Phone Number 715-796-5782 _S 1/4, Section 16 IL Type of Building (check all that apply) Lot # (circle one) 6 T 29 N; R 17 W 8 1 or 2 Family Dwelling - Number of Bedrooms 3 Subdivision Name CSM# 724851 ❑ Public/Commercial - Describe Use S Block # 1---f ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village CSM Vol.17, Pg 4536 X Town of Hammond III. Type of Permit: (Check onl o box o e A. Complete line B if applicable) A' ❑ New System RePlacement System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. List Previous Permit Number and Date Issued ❑ Permit Renewal El Permit Revision El Change of Plumber ❑ Permit Transfer to New Before Expiration Owner 72/ J q IV. Type of POWTS System/Component/Device: Check all that apply X Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ ound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) 5~1 -3 retreat n nexplain) V. Dispersal/Treat ent Area Information: Q ; 04- s 1-7 4, $ 5F r s Design Flow (gpd) Design Syil Application Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation C150 ft 450 0.4 ✓ 1125sf 1174.8 sf VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o e v New Tanks Existing Tanks w a 34 rla U ~ y ti w C7 a Septic or Holding Tank X cu~l 1000 1 weeks X Filter tank X 320 Wieser X VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Mike McDonell MPRS # 225036 612-865-1927 Plumber's Address (Street, City, State, Zip Code) l ZJ 1070 Hunter Ridge, Hudson Wi 54016 VI . County/Department Use Only Approved ❑ Disapproved Permit Fee Date Issued ssuing Agent ign re t ❑ Owner Given Reas ~T__ 77 pasons for Disapprovalc and n Gr Gov - serviced / maintained S" Cf-(~p f]3/ provided by plumbe mus a m aitained dinances. eq~t& a dAk Attach to complete plans for the system ands bmit to the C my only 6if paper n less t 81/2 11 inch in size SBD-6398 (R 11/11) A 6- 17 C~a Az J'oAr7 7e4.7/7e 40 ~ C'o, Qo. T ~et to C'..Sr1 ✓o% /7 /3. 5''S~G T. ofmoyJC✓ oE-•~v~flu'AC~ ¢ (c c,~riG Sei'✓~7-e C.~ dr'L4 =~l X`3 Ea~9~a~ becl~con, U 0 ~L~• = '7.501 6~U3~i`~q c~Jc//--~--~,, ~ r VV ~ O .-.tea f lje~~b ~ 9 - ~~;`k ~ ~Ze61sa TOT Cp' ~I~C` c~ Par pa•~ X1314 \ b~'- ' h/wy. T aP = o l 3 ~Xi sEinG Zo paf. S,d:.,~. /fssumcdt Grl.i .60, ,o6c~Oo+,K. 6/cc! F ,Q 6 z~~ o F o u.E /c ~s~y tok Szs F;1~'nr ~9c.o9' o - ae ro='(~~d.=-9.~•z~.~ EX/:SEs" iz;rsl c!,;~e~'Sa( ~ yz.o'c~nv~ou~ Vt.. J ~ di•SraG/3 a,( l CGfI 4 r'eQ, rp ~ ~ ~ I tre0s 3j'f 3 5 'S f, oti 3Czo.x4L` I Cab~a -c~+a1 Flo THE QUICK40 PLUS STANDARD CHAMBER Quick4 Plus Standard Chamber Side and End Views 5 51's , 7-5-0' 48" z c (EFFECTIVE LENGTH) Quick4 Plus All-in-One 12 Encap Front, Side and End Views r"' 2 3" 8" INVERT 8" INVERT tW17 TM 5.3" INVERT 33" Quick4 Plus All-in-One Periscope DUICK4 PLUS ALL-IN-ONE PERISCOPE (360-SWIVEL ) 12.7" INVERT ouICK4PLUS. ALL-IN-ONE 12 ENDCAP ff Quick4 Plus Standard Chamber Specifications I Size (W x Lx H) 34" x 53" x '12" (86 cm x,;135 cm x 31 cm) 4r , . , Invert Height 0.6", 53", 8.0",,12.7" Effective Length „ 48" (122 cm) (1..5 cm, 8.4 cm, 18.5 cm, 22.6 cm) INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, end plate, wedge and other accessory manufactured by Infiltrator ( "Units"), when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, Connecticut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty INFILTRATOR" does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party, systems inc. Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the minimum ground covers set forth in the installation instructions; the placement of improper materials into the system containing 6 Business Park Road • P.O. BOX 768 the Units; failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the Old Saybrook, CT 06475 terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any 860.577.7000 • FAX 860.577.7001 third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and local codes; all other applicable laws; and Infiltrator's installation instructions. 800.221.4436 (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the www.infiltratorsystems.com original Holder. The above represents the Standard Limited Warranty offered by Infiltrator.` A limited number of states and counties have different warranty requirements. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. For technical assistance, • instructions or customer service, call Infiltrator Systems at 800.221.4436 U.S. Patents 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer, Quick4 and Quick4 Plus are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour Swivel Connection is a trademark of Infiltrator Systems Inc. © 2009 Infiltrator Systems Inc. Printed in U.S.A. PLUS0510101SI-2 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) Tl1is is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: Street address) 90(o Ca RX located at: 5W "4. a. Section Town 21 N, Range /:z W, To it Ol a. /7, St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge> will conform to the requirements of Comm. S4,2 " and It the\ appear(s) to be functioning properly. Most recent date of' inspection or service Z-- Did flow back Occur from absorption system? Yes No (I f no, skip next line.) Approx1111ate 1'OILIMe or length of tlnlr: - gallons I11111utc;s Tank Capacity: _/D0© Construction: Prefab Concrete Steel Other \larlufacturer (if k:11own): wtgv~_ k _5 _ A,.e of Tank (if known): a ~5 Permit number (if known) r7alf'A /if P umber Signature) (Print Nalne) Title) - (License Number) :N,1Pi1lPl6 (Date) 1=onn to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin .-~,lmmistrative Code) R~v. y ?u0a r' 2287 Wisconsin Departmen SOIL EVALUATIOAR P QFVU Page 1 of 3 Division of Safety- B A.C.E. Soil & Site Evaluations ccord ce with Comm 85, WMIc1mr-eudu St. Croix Attach compl e site plan Emsmic pq not Ibss tha %x11 hes in size. Plan must include, but no limited tol and l int (BM), direction and percent slope, le or di ion and distance to nearest road. Parcel LD. 018-1036-60-300 PI48~ nformation. Reviewe Byl Date Personal iMorm n be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 2 2 Property Owner Property Location John & Jeanne Will Govt. Lot SW 1/4 SE 1/4 S 16 T 29 N R 17 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 906 Co. Rd. T 6 CSM Vol. 17, Pg. 4536 City State Zip Code Phone Number City J Village a Town Nearest Road Hammond WI 54015 715-796-5782 Hammond Co. Rd. T & 90Th Ave I New Construction Use: y_f Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ✓j Replacement J Public or commercial - Describe: 7 ~/,3 Parent material Glacial drift Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.4 gpd/sq.ft./day loading rate. Recommended system elevation to be 87.50'. Boring # Boring Pit Ground Surface elev. 91.11 ft. Depth to limiting factor >116" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. " Eff#1 "Eff#2 1 0-11 1Oyr3/2 none sil 2fgr mvfr cs 2vf,f 0.6 0.8 2 11-16 7.5yr4/3 none gr sl 2fsbk mvfr cw 1vf,f 0.6 0.8 3 16-2$._ 7.5yr4/6 none gr sl 2msbk mfr gw 1vf 0.6 0.8 4 28-45 7.5yr4/4 none gr slAs 1 msbk10sg mvfr/ml gi - 0.5 1.0 5 45-65,', 7.5yr4/4none N v sl 2msbk mfr gw - 0.6 ` 1.0 6 65-75 1Oyr3/6 none scl 2msbk mfr as - 0.4 0.6 7 75-116 1Oyr6/6 none s Osg dl T T- - 0.7 1.6 Boring # Boring 1/J Pit Ground Surface elev. 90.36 ft. Depth to limiting factor >85" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 1 0-12 1Oyr3/3 none sil 2fgr mvfr cs 2vf,f 0.6 0.8 2 12-21 7.5yr4/4 none gr sl 2fsbk mvfr cw 1 vf,f 0.6 0.8 3 21-29 1Oyr4/4 none gr sl 2msbk mfr gw 1vf 0.6 0.8 I 4 29'=45 7.5yr4/6 no , a gr sl/Is 1 msbk/Osg mvfr/ml gi - 0.5 1.0 5 45-72 1Oyr4/4 none Ifs/Is Osg ml :W: - .5-" 1.0 6 72-85 1Oyr3/6 none scl 2msbk mfr - - 0.4 0.6 " Effluent #1 = BOD5> 30 < 220 mg/L nd TSS >30 < 50 mg/L " Effluent #2 = BOD5 < 30 mg/L and TSS - 30 mg/L CST Name (Please Print) Signal e: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 4/17/2012 715-248-7767 k • Soi/ eda/ua ~o+-, P; ~ EX~~ f%~~ a alc e /et/ , e, Q,l~W,U87 .7o h n d .Tea4n,e 0;// 90(10 (?0. eo(. -r 0 /~a+nir,oreiI cJ/ 55~4/S ,Let 6 c5p, ✓oI /7 4. v'5-3- 6w9i,'se1*,stc 7%zg/l., 4. /71o')., T. of 4.n,ne"d, I&. cro;xO,., +,JL oF.ouerl~,ead a lecEr;e. Ser✓+t:e U is ~ S bed~io~, +Qes,olcncc . 117- 11 a~ = ~5or+, o ~98.3~~ EWsEi /,~yw.O S,d;~ . ~sskmcd a 6J.•i .co; ~ SC,o6't~aiK. E/erl; ~ at fn~ooFowt/c.~ 0 BB TO.fC6rr1,=91~~J ' S2 ',d; . fZ.o'Ceo6occr EX~Sfs i~ x ,~4cl'SQ/ ee.i/. ~fih~ia+.froe.S~Aee ' C.L!/ o yea. V DQOU 1~ tree 3.3 y ~jc, 3 0{'3 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address co . R&- Property Address ~n (0 co. P-9 -r P)(/< (Verification required from Planning & Zoning Department for n construe on.) FDl $ - l b3&-60-zoo City/State W L Parcel Identification Number LEGAL DESCRIPTION Property Location,5 141 '/4 '/4 , Sec. , T c~ 9 N R 1-7 _W, Town of OQ Yn 010 X Subdivision Plat: C S M V6(,171 . 'V6_3& , Lot # ~O Certified Survey Map Volume Page # S 3 (o s`f Warranty Deed # 5Z7 ( (i (before 2007)Volume Page # Spec house ❑ yeXno Lot lines identifiable yes LFI no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper rnaimenance 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 & Zoninu Department within 30 days of the three year expiration date. 1/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms .3 O-JL~ C/ 2;4 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) uv~:1 ;STATE BAR OF WISCONSIN FORM 5-1949x. 4-.-- ..~ec...~.- c..~ zcc....-rY..... Y=. PERSONAL REPRESENTATI'VE'S DEED 52 3 - A t" VOL ~T C Wanda Madsen .a.nd.-Ja.mes_ Kriz_gk . as Personal RepresentativeSof the estate of MAR 3 O 1995 Harriet Krizan s A..., 4! r't 10:45 1 zi.o c S j , ("Decedent"). for a valuable consideration convoys without warranty, to f'. John C Will and Jeanne M Will. hu_sbanKj 4i wife as survivorshn__marital _property__,__j$/__ Jch-jjZm:j_Y.41.1 I a-A,. '1,~1'll'1P Marie X'iI111._ Grantee, RET-„H To the following described real estate in S t - .C'r V i X ..County, State of Wisconsin (hereinafter called the "Property") Part of the SEk of SE34 of Section 16-29-17 ,j described as follows; Lot 4 of Certified Tax Parcel No: f! Survey Map filed March 7, 1995 in Vol. "10", page 2887. I ' i h 07 Co / °_y,° l i i; Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. ! Dated this ------2..th-•- • say of ,._...._..._.•rlarch..-•--.._ 19.95_.. I I k '~.d~C/Grli •....t.:!.-W ...(SEAL) iara'~+~~a~. \ G~•*~ _ (SEAL) e Wanda Madsen Jame,s Kriza>?............... I(I(= CO- Personal Represetative C.O- Perapnal Represen Gttve AUTHENTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN f r as. St. CroS.x i County. authenticated this day of 19 Personally came before me this day of j i1afiG~J 39..c3 3.. tho above named , -a>a a---M a sex.---arid-----<---------•-------- • James Krizan 1+. TITLE: MEMBER STATE BAR OF WISCONSIN i! (If not. authorized by $ 706.06, Wis. Stats.) to me known to b person .5 who executed the fore ing tru ent a d ctxknow3edgea Wme. .THIS INSTRUMENT WAS `JRAFTED BY - C , L. Gayaard, Attorney- 7 ~//.c° River Fa11 s WI 54022 Notary Public .C_... Count , Wis. f (Signature,:; may be authenticated or acknowledged Both My Commission is permanent (If xtot state expiration are not necessary.) date: Czi. 4.._... 49 it i •N►mea of persons signing fn -y c.D.,Ify should be typed or print,d bef- their eignstcrea- F010-1 o. ssr; H GMdle • No. 5 - 108 lae2 StcadZ'tIn ,i'i 3QI'?~` POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page f of FILE INFORMATION SYSTEM SPECIFICATIONS Owner \Ali l/i / Septic Tank Capacity ~(1U gal ❑ NA Permit # w7v . Septic Tank Manufacturer S ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer z L~~C ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units _J2 11A p Tank Capacity rl LIZ 3 2v gal ❑ NA Estimated flow (average) (fib gal/day P p Tank Manufacturer W ❑ NA Design flow (peak), (Estimated x 1.5) ) gal/day Pump Manufacturer ,12 A Soil Application Rate 0, gal/day/ftz Pump Model NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil & Grease (FOG) :530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) :5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Disp al Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) :530 mg/L nn-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :_30 mg/L HINA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) fu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ye in di ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Insect condition of tank(s) At least once ever ❑ m th(s) (Maximum 3 ears) ❑ NA P Y: earls) Y Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ rrppoonth(s) (Maximum 3 Years) ❑ NA 17Yyearls) Clean effluent filter k S a~b At least once every: ❑meonth(s) [I NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page y of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replacement system: VA suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. /N/~"► Jib T aluat t be a ai ?914 418 rr1~ nR- A 161J C0NJS 7e(!~t 0 tank ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat attlthe infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name C 11-1) Name 77--/ el t;_7 Phone Z . _ GI .1-7 Phone 1'7/ 5 ' Z ~T SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ST. Ckb l b u ZD~ I AJ Phone Phone 3-Cp- (D This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. 72465 1 MAY 1 1 20Q4 vol. 17 PAGE 4536 KATITEM H. WALSH REGISTER OF DEEDS ST. CROIX CO.L NI T MI ~'tiTY RECEIVED FOR KECORD C D 06/06/2003 12:16PM t CERTIFIED SMAP CERTIFIED SURVEY MAP LOCATED IN PART OF THE SOUTHEAST 114 OF THE SOUTHEAST REP FEE: 13.00 COPY FEE: 3.00 1/4 OF SECTION 16, T29N, R17W, TOWN OF HAMMOND, ST. CROIX PAGES: 2 COUNTY, WISCONSIN ALSO BEING LOT 4 OF CERTIFIED SURVEY MAP RECORDED IN VOLUME 10, PAGE 2887. SURVEYOR: DOUGLAS J. ZAHLER PREPARED FOR: S & N LAND SURVEYING, INC. JOHN WILL 2920 ENLOE STREET 906 CTY RD. T HUDSON, WI 54016 HAMMOND, WI. 54015 °w APPROVED ST. CROIX COUNTY Woo Planninn 7oninn and Parks Committee S E1/4 COR. w - - - - - I JUN 0 6 2003 SEC. 16 W U) (S89°38'00"E) `U Co N89°43'44"E 2 O - TflTot recorded within 30 days of W LL o 418.46' approval date approval shall be and O W N nJl! kind void o z~ Q o f r4 s dQ4_~~o~o o WISO O,y O N dOd°_o`77 I Co NCO co j~ DOUGLAS J. Z t0 W ZAHLER " 5-2145 '45' 50' I ~W HU O R1 (S88°50'1 7"W 362.31') 45.09 915' 00 N88°12'01 "E 362.38' O N 317.29' 40' 50' I I ~o J S00°01119"E O V 6.97' I I o " i] ' N89°56'57"E 358.68' NS 5.00' I~ i@ iO SOIL•RING T C/) LOT 6 _ S o I ;D N Cl) 9.485 ACRES 8 r g6 I ' Z O 413,166 SQ. FT. m Cn 50 C'D °o LOT 7 w INCLUDING R/W 21 -j" ° c ao' 48' i~ l^S,, I V V Q, ° ° 8.555 ACRES = rTl N g i&T w O 4.197 ACRES M O N I~ i0 i° m182,802 SQ. FT. 37 L,681 . FT. Cn UDINGQ R m coO EXC /VV m INCLUDING R/W A 08 0o ~i° vW v CTI 0o w - -I N I~ l0 3.885 ACRES OD SHEDS I° cn I I I N (p I 0 00 I a I 1 69 242 SQ. FT. EXISTING DRIVE I r .p - 4' EXCLUDING R/W 6) i° m ) I7-4 Q Ut BARN WELLn li~ Q~I I- i o0 F7 ` N rnl, Vvl HOUSE p O 50' SET-BACK EXISTING (Q EXISTING0 ~I W I S1/4 COR. ENTRANCE DRIVE St PTIC SEC. 16 EXISTING DRIVE N87°06'04" 2' (D• I I i~ 74 • I ~ - - 345.86' (S86°27'43"E) - 40' 48' 397.06' -OI CM0 41.07' Cf) - 344..67 w 37.53 7 8837_98', co 438.08 ~ - N87°40'52"W_ 782.75'- 93 (D - SOUTH LINE OF THESE 1/41-1_@) 04M -"(N87°0Z46"W 782759') - SE COR. e -S87°40'52"E- Qd-~~~ SEC`16 -2620.73'= I (N87°02'46"W 2621.12') I 818' I MG~pdIQ _It~4__CD [~1~1D~_ LEGEND FOUND ALUMINUM COUNTY SECTION CORNER MONUMENT SCALE IN FEET 1 150' ® FOUND 1" BERNTSEN SURVEY MARKER FOUND 1" OUTSIDE DIAMETER IRON PIPE 15 0 0 1 50 0 SET 1" OUTSIDE DIAMETER BY 18" LONG IRON PIPE, WEIGHING 1.13 LBS. PER LINEAR FOOT EXISTING FENCE M THIS INSTRUMENT DRAFTED BY: WES ANDERSON 100' ROADWAY SETBACK JOB N0.6170-01 RDATE: 8/05/2002 EVISED 9/03 SHEET 1 OF 2 SHEETS Vol. 17 Page 4536 Fo rm - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. ~Co T 9 N-R_LLW ADDRESS t~ ST. CROIX COUNTY, WISCONSIN SUBDIVISION ~j,~J✓ LOT LOT SIZE;/ i~ PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I V6 1 l a~' 31 d ?7 5~ 23 Ve III t 7,1, INDICATE NORTH ARROW mh BENCHMARK: Describe the vertical reference point used, Elevation of vertical reference point: i?)O-o ' Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: v Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: 9 1'2 1 / Number of feet from nearest Road: Front 10 Side,) Rear, O /Oz feet .From nearest property line Front,O Side, Rear, O feet Number of feet from: well J73 , building: 32 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 1 PUMP CHAMBER Manufacturer: Liquid apacity: Pump Model: Pump/Si Manuf cturer: Pump Size Elevation of inlet: Botto of tan v tion: Pump off switch elevation: Gallon er y le: Alarm Manufacturer: Z Ala witch pe: Number of feet from nearest property line: Front, Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Xf Trench: r Width: /J~ Length: Number of Lines: l Area Built:,' 7 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ® Rear,O Pt. 70 Number of feet from well: 95" Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pit • Dia Liquid depth: Bottom o seepag pit e e Aaton: Area Built: Has either a drop box O or distri tion ox been u d on ny of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capaci y: Number of rings used: Eleva on of otto o tank: Elevation of inlet: Number of feet from nearest proper li e: r n , Side, O Rear, OFt. Number of feet om w 11: Number of feet fro builds Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING t MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE Sfall Plan I D. Number: (II assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOL°`ER: ADDRESS OF PERMIT HOLDER: INSPEC ION CIATE Harriet Krizan Hammond, WI 54015 9F(.PT. d fLe o BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLANRLEV.: CST REF. PT. ELEV.. SE SE, SEction 16, T29N-R17W, Town of Hammond Name of Plumber: IMPIMPRSW No, County Sanitary Permit Number: Dale Hudson 6629 St. Croix 79139 SEPTIC TANK/HOLDING TANK: .,I?, MANUFACTURER: LIQUID CA ACITV. ' TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL JLOCKING COVER PROVIDED PROVIDED. /DOD yJ .07/ YES ❑N0 ❑YES ❑NO BEDDING: VENT DIA.: VENT MATT HIGH WATER NUMBER OF ROAD. PROPERTY 1WELL: J BUILDING: VENT TO FRESH LINE X T AIR IN~fT. 7 j • ALARM FEET FROM Z 7e 7L/ YES ❑NO ❑YES NO NEAREST OQ too DOSING CHAMBER: MANUFACTURER BEDDING. ILIQUIDCAPACITY JPUMP MODEL. JPUMP,SIIIHON MAN111 AC T1IHEH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF IPR' )PEHTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST-~ SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing ;TE/+ 111ATI RIAL AND MAHKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: _ WIDTH. LENGTH NO OF IS TR PIPE SPACI N(I COVER INSIDE DIA -PITS LIQUID BED/TRENCH THENC s MAT IAL PIT DEPTH. DIMENSIONS (p GRAVEL DEPTH FILL EPTH UISTH PIPE UISTH PIPE DISTR. PIPE MATERIAL NO + NUMBER OF - PROPERTY WELL. BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER EL LEI ELEV ENU PI FEET FROM LINE AIR INLET. v. NEAREST D D /Q L MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL .`OVER [TEXTURE III RMANF Ni MAHKF RS OBSERVATION WELLS _ ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH REU DEPTH OF TOPSOIL SODUFU SEEUFD MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL jN-O-DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. DIA. ELEV. PIPES DIA. ELEVATION AND PLA 'S DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORHECI LV COVER MATERIAL VE R TIICAL LIFT CORRESPONDS TO APPROVED ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS. NUMBER OF PROP ERTV WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO _ NEAREST _ Sketch System on Retain in county file for audit. Reverse Side. SIG ATU E TITLE: DILHR SBD 6710 (R. 01/82) a oc) (mo t qu q. ° d c, h `yy p~ tlrt" ~ tV1 t A w Ilk Qy- yl Lu d 3j `1c ft7 tj SP, a H z • 'cn H a ST C'-105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a OWNER/BUYER ROUTE/BOX NUMBER Fire Number CITY/STATE ZIP PROPERTY LOCATION: Section /lo TAN, R17 W, Town of St. Croix County, Subdivision N~ Lot number. 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. yo I/WE, the undersigned, have read the above requirements and agree En to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P. 0. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT STC - 100 Y This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequavies 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 Property Section /2~~ , T x0al N - R W Township Mailing Address: Subdivision Name /V fT Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number '722 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 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 OW14ER CERTIFICATION I (We) ce LaS y that att .6 to temen to on th i A 6on.m ane .twe to the beat o j my (oun ) know.eedge; that 1 (we) am (ane) the owneA(a) o6 the pnopenty deAcAi.bed in thiA .in6oamati:on 6oAm, by vi tue of a wwmanty deed neconded in the 066,iee o6 the „-.,,County Regi,&teA o6 Deeda as Document No. and that I (we) p4e6entry own the 'pn.opo4ed ad to bon the 4ewaga t4p-oeakayatem (an I (we) have obtained an mement, to Aun with the above deacAi,.bed pupenty, bon. the con tkuction o6 aai.d ayb.tem, and the flame has been duty teconded in the 066.ice o6 the County Reg.i a ten o6 Deeds, a6 Document No. I SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 29~ DATE SIGNED DATE SIGNED 2 r- ~O w. > O c _m 'O CD p C y _ C R1 W • c - O c 3 -W pf a o O O O E ~v r L-c 0,0 a) c cm 0 U) r- W 0 m'a , C a) 0 3 00.0 ..3:3 0.0 vEc 0 L m N N c 0) p o N ~P O °bt a) - fn a) U) C .C a) Q c c(D a Y= E o W y 3 U m - L- Z c~ N a Cl) ~C'~~_N~ t `c Lu 0 V =O L ' C l~U o w N C d) rn " 3: z CD Q U O C O O O N Z c~~ j M c0 O Co LL a 1. ~ 0'3 ccu3>. -1.- cn ~ m Q Z N m a? " U) U) tv CL _ m CM a) = O 3 O p p co cif C O ~ t Q O V U cu a U p in 0 ~ O Q O ~ p N Q an~co 0- c a` )'U 0CY) o m _ca o s c CO c (1''-" 'c-cc cu 0 3 cm .c- s cc c U~ o E > 0 O C t ~ ~ O cd O 'C -c c0 Ch 0I O -0 E U u co L c O U ~L... C Jbl U yin N L- N p_~O :r F co ca ca a) Y O N U C O v O fC U D n 01 C 3 N 3 a`) rn a> > L a o o O cn N N C CL E - O CL Y Cl) O E c o)= 13 C m " m m 0 a 0-0 O rp CD cc c = C) E .0 ~ _ S 0 ~ O c p 0 L C 0Ec„u~,NY~ Ho3 m c ~ J y C INDU! RT NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS tNQU~TRY, D1VIStON, LABOR AND PERCOLATION C P.O. BOX 7969. HUMAN RELATIONS TESTS (115) MADISON, WI 53707 (H63.090) Sr Chapter 145.0451: LOCATION: S SE TIONt TOWNSHIP/MUNICIPALITY: OT NO.: BLK. O',.: SUBDIVISION NAME: e. 0 / /jgg N/R 71 (or .aa /,L/ 4117 COUNTY: OWNER BUYER'S NAME: MA N ADDRESS: 74 USE DATES OBSERVATIONS MADE NO.RFDRMS.: COMMERCIAL ESCRIPTIO r-~ IPROFILE DESCRIPTIONS: PERCOLATION TESTS: LJNewReplace L !1 O Residence -7- J r fey . ~ 3 RATING; S= Site suitable for system U= Site unsuitable for system ONVEN I NAL: MOUND: IN-GROUND-PRESSURE: ISS EM-IN-11LLHOLDINGTANK:RECOMMENDEDSYSTEM:(optional) QS ❑u MS ❑U NS [:]U [:]S RU ❑S NU n74_ 4o~ r I If Percolation Tests are NOT required DESIGN RATE: ( If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H TO R UNDWATER INCHES CHARACTER OF SOIL WITH 'THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER ELEVATION OBSERVED T. H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) P ~ 9/ r • B B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHFS AFTERSWELLING INTERVAL-MIN. PERIOD t pERI p PER INCH P-`IO 2,191 AA 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 -7."' r I - s - i E f , IN .a p y o j i , r , 3 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): Id, CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soit Tester. DILHR-SBD-6395 (R. 02/82) OVER I i ca o -c tal - o v ~ ~ Q