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HomeMy WebLinkAbout161-1092-10-000 3 0 CD C) o „ O p w a M 4 O N O ' r (D LO 0 c z ° 6 z 0) 7 m 0 7 ca LL c 'D LL c O N O C a m a U w z N N Z r O 0 d P C "0 N a m I a m M i Z C C ~l O O O Z d c U cc DV 7 m - 7 n zt 2 o o to Z ? aci Z D Z S; E -o c -D -p M ~r]^ -D CD N Cl) (D j a) N j N N 7 N U) h Y) n • N N O p Q V C U Q Z H Z o z co z o N p Z Z r 'lot _O m E O C NI E O N N ZZ a) O I d_ O 5 o a 'm « c co co 2 N W N i N Z O O W d N L c0 0 CD 0 0 a L U o c a -O U (O N N in H F- F- 7 w F- F- F- 7 _a N Z d= Z X 3 3 0. Z O o 0 0 0 c 0 0 0 • Ai a a a o a a a c v y 2 v v 7 0 fn J U ~ ~ ~ O 0) O O i z M r N $`.t O rn I N N- 3.= o M O O _ O E J O _ .Q 7 0 N 7 dt _N c 7 N m U C: co c a ) ~ M C Q Cn Q ( N d Q 1- in Q J 7 w LO O 7 w C °6 N C N N C p O Q O E_ I M O E N CO V 3 I Y aUi c c a rn CY) W 4 0 L) a C) 0 O C O\ C O C m C N N I~\y _ C y 7 N O "D Z s0.+ V N M H N rn 2 (=D Z Z c m ° c oo o c a~ • ~p 7 O O N ca m m =p ~ O N N E N v 2 C N O z co > LO O z 2 F fn CL a mat a' Lam Law • t~ c. m .2 d d c d O c E ` c c t A Ua~ ov)V ,0NU ~ a S TC - 10 4 AS BUILT SANITARY SYSTEM REPORT {u OWNER AON -sC~T !J'/'Tt ADDRESS SUBDIVISION / CSM 5r- 4eel-X 5rt1-7DA,~ LOT # l SECTION 13 T N-R 30 W, Town of /f!>~,rD,J ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ORIGINAL see fTTfa oe~zeor Ski ~'c %1 'mot ~ rEs ~~,v,~ vy Ev p ~ ly e"rei-. Govwr /SOX s- w~5 Gvrt-5 i.vs~r fI New 3 _ W A lv~-s ~v/DAD So •Y . ~S-ee ! qgy A57- 0 v (41T) -c4kl E' ~~,,,?ZSEL~ G- 1~= mot. INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. k_ BENCHMARK: 5' L O / calo y t= ~ ALTERNATE BM: J - , 'F Q oAx ,pc •u sErp drX sn-ij 6-- ( 3)l 4 y~ SEPTIC TANK / &BE R / ON Manufacturer: wE~~s COW AVM Liquid Capacity: ~ZUd C:Q Setback from: Well 70 House /S~ Other Pump: Manufacturer Model# _--'S i z e Float seperation Gallons/cycle: Alarm Location l' T , 4 r. wow A V ' , OIL ABSORPTION SYSTEM i Width: J Length X60 Number of trenches 2, i L Distance & Direction to nearest prop. line: -SD Vd-A- L. i Setback from: well: House (APO Other IL SEPP'C- 7-4,~,k 1g111- ELEVATIONS 4!P176-P, "'00.0, </Vo ~ fs&ws Building Sewer ? Soh Inlet : 2• ST outlet `F7 72- PC inlet PC bottom Pump Offf Header/Manifold Bottom of system Existing Grade /00.0 Final grade 9b• 7J y DATE OF INSTALLATION: ©G/ • .2, 1 ~ 2- My PLUMBER ON JOB: yc)5~kT- ~LI5 I~GGt~T' LICENSE NUMBER: M AqS 33© "7 INSPECTOR: 1;~ 1, A3 S ~5 5 r' 2,0~ fZ6- Add 3/93:jt ~ o N °e c d N O p` y o r ~ N C >N o e A N o I 0 I ST~Tio~ G,✓ s'" Ll b w Vs W (l O' ~ y ` Form -=STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Vf~~-Q ~a~'✓ TOWNSHIP 110,4910A-" SEC. T N-R ~d W ADDRESS ST. CROIX COUNTY, WISCONSIN 51- ewrw SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LUR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM it V • i 4dm o c. r. 17 is.s• U~ w Ertl G G G Va ya ~ ~ - - - y 33 4077z/ 40 - L INDICATE NORTH ARROW G BENCHMARK: Describe the vertical reference point used 2r-Z/57 3 -;F- Elevation of vertical reference point: /00.0 Proposed slope at site: / 570 SEPTIC TANK: Manufacturer: 6)1G~ Liquid Capacity: Number of rings used:- Tank manhole cover elevation: Tank Inlet Elevation: / 1--(, Tank Outlet Elevation: Number of feet from nearest Road: Front,© Side o Rear, O O d feet From nearest property line Front,O Side,0 Rear, O .5 5 feet Number of feet from: well / / ` 9 , building: / S 'q- (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer. Liquid Capacity* Pump Model: Pump/Siphon Manuf urer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevatio Gallons per cycle: Alarm Manufacture Ala Switch Type: Number of et from nearest property line: Front, O Side, f~ Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: R Width: 7 Len$th: -S! Number of Lines: Area Built: Fill depth to top of pipe: f Number of feet from nearest property line: Front, Side, O Rear,O pt.ao Number of feet from well: ~S J ' Number of feet from building: 31 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter.: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: 4 Inspector HOMESITE SEPTIC PLUMBING CO. Dated: Plumber on job: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRICHT License Number : WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. 111MMEEIER 81 %-IkO It* NO. --3 3/84:mj Wiscons Departr9entofIndustry, PRIVATE SEWAGE SYSTEM County: Labor amd Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI o.: MOSCA, RON X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax o.: r s p / U U ` c3 Cory' ~(c TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic l j z / aoo Benchmark /00, Dosing Aeration Bldg. Sewer Holding St/Ht Inlet r TANK SETBACK INFORMATION St/ Ht Outlet 4- y5 17.7 TANK TO P/L WELL BLDG. Ventto Air Intake ROAD Dt Inlet Septic >10 ' 70" NA Dt Bottom Dosing NA Header / Man. U Aeration NA Dist. Pipe of ss?L 9 9 Holding Bot. System 7. ~x x`/``17 ,F8 9u, . 7 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Lrictio System TDH Ft oss Forcemain Length Dia. I f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S /v ca 2 DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO CHAMBER Moe Number: System: /U , 6O C A OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over 1, [o xx Depth Of xx Seeded/ Sodded xx Mulched 9,l0'd Bed /Trench Center Bed / Trench Edges r Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) r, Gyre, LOCATION: HUDSON.13.29.20W,NE,NW,LOT l,STATION LANE ` 1-,,, P~ ^C q ' Plan revision required. ❑ Yes Use other side for additional information. /C")``~` SBD-6710 (R 05191) Date I pecior's 'Sig nature Cert. No. 1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i ~I i SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouNTY s-i : ~iPo ~ yC STATE SANITARY PERMIT # -Attach complete plans (to the county.copy only) for the system, on paper not less than 8% X 11 inches In size. 1:1 g 917;1 Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION lzv /Vt_%41V1., S 13 T a'f, N, R W E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # , BLOCK # 3L37 S Arr7d"a L-t_-) _ 74 5: 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER o~ s- r- cto f X STS T{`o ~J II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned O VILLAGE `rV $r~ j/DAJ LN ❑ Public [E 1 or 2 Fam. Dwelling-#~ of bedrooms PARCEL TAX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Chec?ony one in line A. Check line B if applicable) A) 1. ❑ New 2. placement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System i B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized"Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure / 43 ❑ Vault Privy 14 ❑ System-in-Fill ~~----aa•• 2 Tr Ej e4t S -z-44e., VI. ABSORPTION SYSTEM INFORMATION: 7 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) c ELEVATION &0 !O"va 05- 1 • G Feet 5'7,7 Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed _7T F1 1 171 F] I El Septic Tank or Holding Tank 200 7100 Lift Pump Tank/Si hon Chamber- F1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPfMPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 01 6S5- ® 'Aver/ -0"-) ! S' Sow IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanit ry Permit Fee (Includes Groundwater ate Issued Issui g Agent Signature (No Stamps) Approved El Owner Given Initial Surcharge Fee) ~ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS ' 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 any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) 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 adm;nistrator 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 system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms it 1 or 2 Family Dwelling. III. 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 l l 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 tank(s), 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 focm;,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. I I SBD-6398 (R.11/88) ~O b M `l tt ~ 0 P- O ~ j w v~ h NE) - 07 n-0//Vt,5 W ~ h 0 c o, \ L~ X, S - - Ell- It ~ ~ 2 ~ • G ~ x ,s 41 hj BYO Pt- CAI U. 0 r sps-c-5- yP Fresh Air Inlets And Observation Pipe Approved Vent COP Minimum 12".Above Final Grade „ a 4" Cost Iron 36 Above Pipe Vent 'Plp.e ~o Final Grade Synthetic Covering min. 2" Aggregate Over Pipe Distribution ,t ---Tee " Pipe 0 0 0 0 0 1 Aggregate 0 Pertbroled Pipe Below Beneath Plpe o Coupling Terminoting At Bottom Of S.ystSm 5 f % • j ST. CROIX COUNTY ZONING OFFICE C. TIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the „RD.tJ 1q,0 residence located at: I VC 1/4, Al 1/4, Sec. 3 , T 2-f N, R W W, Town of i-(jpSO•.J Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. cc Last time serviced ©071. ~I l Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: 7 ~d gallons 2- minutes Capacity: 1200 Construction: Prefab Concrete Steel Other Manufacurer (if known) : WE-4G-e-5 v Age of Tank (if known): (Signature) (Name) Please Print (Title) (License Number) (Date) Farm 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, Wis. Adm. Code (except for inspection opening over outlet baffle). Name PoB .6t/ Signature A?Lel ~-KPVMPRS 3302 5/88 Wisconsin DepartmentRelati tions Industry, SOIL AND SITE EVALUATION REPORT Pap,,r 3 Labor and Human Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY .ST C,t°o .'X Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION k"O"V if p5e l - GOVT. LOT if/,6- 1/4A/01/4,S/3 T27 N,R 30 E (or) ,W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 32.6- STATION L,U • / ST o',Po1x ST~Tio.✓ CITY STATE ZIP CODE PHONE NUMBER ❑CITY (VILLAGE rk-rOWN NEAREST ROAD i! fi~UOSa^•' C!J/. Sy0/Co (7/f 3P(~"Db'97 F+ul~s°,~ ST.t-Tio,~. ~.v . [ ] New Construction Use [Residential /Number of bedrooms y [ ] Addition to existing building 14,Aeplacement [ I Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate ' S bed, gpd/ft2 trench, gpolft2 Absorption area required bed, ft2 /00 trench, ft2 Maximum design loading rate S bed, gpd/ft2 trench, gpd1ft2 Recommended infiltration surface elevation(s) Pg . 3 93. So ft (as referred to site plan benchmark) Additional design / site considerations SSE GDi`'~' ~'f1,t'P6/.v 7,f'£uCG S - (3) Eq G>r., S ' X 6 7 Parent material S ~S .S7 #Vg6,¢"p1) 5 Flood plain elevation, if applicable N~ It s S =Suitable for system COyyt`WI0NAL M_ OU~40 IN G_ R~IdNfl PRESSURE AT_GFi9pE- U B SYS TEIN FILL -HOLDING NG TANK U = Unsuitable fors stem L~~'S 11 U 1216 ❑ U $ ~ -S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench E3- / 10 12- /o //e 313 74 d,'f w 3, .5 . /D Y,~O- 3/l / f ,P s -1 , s Ground 3 /f~ 9~ 7 4"J S ~,e S ele54, yy ft. . Depth to limiting '•factor ~T Remarks: a Boring # c" 7 Ground Z ' yid 3~~ !S 7` S 3 S elev. 3 7S y/? y~ S• D, S d - S 17-, _L(2 ft Depth to limiting factor p fl Remarks: CST Name:-Please Print ~p3 r Z/L/~/~ /C Gr T Phone: 7/S 3 Pa c0l RS Tess: ~✓~j~- !~'ti~/G 7~D ~IUOSO AJ ZVI- J'ya6 ~ y CsT--/i9/P2_ Sgnature: T 6kAk Date: CST Number: 1111o Ti- .eviGeGyca 7r4o Af ORIGINAL e-1 5-7,r /3, 13 3 ge' ti~~v To 13,~/~4U 0 df7~ . PROPERTY OWNER SOIL DESCRIPTION REPORT Page? 013 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxx~ry Roots ,iPP in. Munsell Qu. Sz. Corn Color Gr. Sz. Sh. Bed Trench 01/L /Oy/f 343 7-5' 7 -re 747 d"Z-q A VI? 316 4V 3 l, Ground 7 $ S D , S d~ - S elev. ft. Depth to limiting factor Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor • Remarks: Boring # Ground' elev. ft. Depth to limiting factor Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor J Remarks: con 0130^10 ^cmIM JAVPI~o r CS V O Q -4, T• N O o 1-14 LTV . r r~ IN N fn rn ~ c y ~ v y I ~ m f, w w ~ 0 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNF.RBUYER Roy CIO rc,,4- 06 f MAILING ADDRESS 3 2 S STET i a.&) L,j ND • [1-y iose j S y Dr PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE 2d PROPERTY LOCATION NE 1/4, NUJ 1/4, Section 13 T 2 N-R W TOWN OF H-VoSD,~ ST. CROIK COUNTY, WI SUBDIVISION 54 " " t X ST~tTt b~J LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if neede(' by 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. 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained st a complete and retu ed to the St. Croix County Zoning Officer within 30 days of the three year piration d e. SIGNED: •~~i DATE: (o `1 St. Croix County Zoning Office Government.. Center.... _ : _ . . _ 1101 Carmichael Road 1 Judson, WI 54016 11/93 i STC-100 This application form is to be completed in full and signed by the owner(s) of t11e 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), thenla 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 ~D Location of property /VE1/4 -*V W-/4 , Section 13 , T 2( N-R 3 0 W Township _"1950P,) Mailing address 3.- S - 3f AT f aO 44V950„~ ~~S• ~y~l Address of site Subdivision name ST - &tz Si _Lot no. -Other homes on property? - yes c~No Previous owner of property ✓AIEF -IO Total size of parcel VO i- A CA- Date Date parcel was created j Are all corners and lot lines identifiable? _~<Yes ~/No Is this property being developed for (spec house)? Yes vNo Volume /aS 7 and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid. delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register o'_ Deeds as Document No. -;*///-70 , 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 instruction of said system, and the same has. been duly rec d d in the office of County Register of deeds as Document No. . Si a ure of a licant C applican Date of Signatur Dat of S mature t n,•s 5rr Rt,-:xxEO Docii.1.-rrT r~c~- W:~A11A`~lTi DFEos STATE fj:~it OF RI ~cO.NsIN FOi3)'I 2~ ~o ~.a REOS ER'S Or FIC S7. CROIX Col. VA DAL E. JOHNSON aLid JOdN L. JOHNSi)N, husband and wife, _ _ Rer'dkf f±p_'otl Grt ltors.._ - DEC 2 9 1993 - - - - - at 11:4 A.m con y; and warl i to to RONALD J. MOSCA Ltd EE ILAb U 104' G al o e rt SSA, su_sbaid and-wife as, survivorship mat it - I~ REiUIY TO ; i St,. -Croix ..Cou..tyx - the follu..l^g descnhed real estate ii, . State of Wiscensin: Ta.t Parcel No: - r'. Lot 1, St. Croix Station in the Village of North Hudson, St. Croix County, Wisconsin. >b s~ ~0 TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if any. This is---_--_.-- home,tcad property. (is) (is not) Exception to warranties: December 19 93 Dated this day of - (SEAL) D LF. E,_JOE;N' N - (SE:ALt _(SEAL) N L. JOEL JOA SON J . AUTHENTICATION ACBN0WLEDGM, NT STATE OF WISCONSIN Signature(s) ss. ' St. Croix - County. authenticates this .-.-__-day of-------------- - 19. Personally cause before me this Decerfx?.Y.._-------_---., 19-9.... the above named Dale--E,_-JOhnson__an.d-Joan L._ Johnson • - - TITLE: MEMBER STATE BAR OF WISCONSIN (If not, . - - - - h te,- th authorized by § 706.06, R'is. Stat.) me known to h the pxr onS._ w u e~.u? 1 the ,~f1 ; r.i "'nt an~I uk.r,ti!c(!ge the sa le. tr , TH:3 ;NSfF.UM^•VT WAS Dr:AF"1ECY'M✓•7 ,t Nn Y Attorney Barry C. Lundeen STArE" 0 Ifll(~T, P ~LCK & LUS ( / Croix Iti ; St. rl~ `5 110 roGt' 4t~'E zi Hu- ;n) Wi SL>il lo n ti c 7 Si ~ a r, ,,y be or a"': _.V, 1. Rath are not races ary-) date. W,5cooslc Leda' 0ia 'nc {ArAP_?..>TY D£F'D FORS 110- 7 1+K4 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER u/1/0 ~sv~'✓ TOWNSHIP 11UdPSO~ SEC. T Z N-R 2d W -V ADDRESS '~~J L~ GtJ,QST ST. CROIX COUNTY, WISCONSIN 5~• ~i'X S¢,y-troy/ ~ / SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LUR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I~ V ~l #/4M M*J tea` to re S<~ lF= j 3d v~ 33 QZ y ' INDICATE NORTH ARROW G T~ BENCHMARK: Describe the vertical reference point used i Elevation of vertical reference point: /00-0 Proposed slope at site: /670 1-2-DO 14-P - SEPTIC TANK: Manufacturer. . 4WD Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: / Tank Outlet Elevation: / -7 ' Number of feet from nearest Road: Front,@ Side o Rear, O o d feet From nearest property line Front,0 Side,O Rear, O feet q Number of feet from: well (0 ! building: /S- S (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer. Liquid Capacity- Pump Model: Pump/Siphon Manuf urer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevation- Gallons per cycle: Alarm Manufacture "Ala _Switch Type: Number of et from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: 3 Width: 2 7 Lenth: Number of Lines: Area Built: Fill depth to top of pipe: Fr, Number of feet from nearest property line: Front, G Side, O-Rear, 0 Ft.ao Number of feet from well: Number of feet from building: 31 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: 4 Inspector: p' HOMESITE SEPTIC PLUMBING CO. Dated: '~v 12 Plumber on job: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRI H License Number: WIS. MASTER PLUMBER LIC. NO. 3301 MAR.S. MINN. BE610IER 1:46. N9. 90663 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 MADISON, WI J3707 C CONVENTIONAL 1:1 ALTERNATIVE IS,,,, Plan LD. Number: (It assigned) O Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Daft Joh"on CloS.Peteuon,Gaeahad Rd,N.Huclsan, W1 '2 _J_7_ Cry / da ntiJ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: NE NW, Sec ion13, T29N-R20W,Lat#1,St.CnLoix Stati.an,Tawn c6 Huct6on Name of Plumber: MP/MPRSW No.. County: Sanitary Permit Number: Rvbent UtbAic:G 3307 St. cuix 58881 SEPTIC TANK/HOLDING T K: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL JLOCKING COVER 1 G g P O DED: PROVIDED: L. I U 30 :A , YES ONO E~~ ~NO BEDDING: VENT DIA.: VENT MAT L: HIGH WATER NUMBER rOF ROAD: PROPERTY' WELL: BUILDING: VENT TO FRESH ALARM: IFE ET FRO M LINE / a AIR INLET. U DYES CXNO 1 DYES ONO NEAREST DOSING CHAMBER: ID CAPACITY JPUMP MODSIPHON MANUFACTURERWARNING LABEL JLOCKING COVER LIQU MANUFACTURER: 71NEGS PROVIDEDPROVIDED. ONO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ONO NEAREST )w I SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLIN~jH JILIAMETER MATERIAL AND MARKING 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 DISTR. PIPE SPACING. COVER INSIDE DIA.. *PITS BED/TRENCH TRENCHES. MA L PIT DIMENSION . LIQUID L' GRAVEL DEPTH FILL DEP H JOILS PIPE DISTR. PIPE MATERIAL. NODI NUMBER OF PROPERTY WELLBUILDINVENT TO FRESH fy le~ BE LO P~$: m C VERV. I, ;LET ELEV. END O~ -Z- 7~~ PIPES. FEET FROM LINzo r I'~ AIR f( T'f,/~ 5 1 (''11 NEAREST ly/S ~ MOUND SYST 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. DYES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ONO OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED: CENTER. EDGES. DYES ONO DYES ONO DYES ONO 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: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV.. DIA.. ELEV.: PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: 7ERTEAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LINE: WELL: BUILDING: FEET FROM : ❑ YES 1:1 NO El YES D NO NEAREST a~ Sketch System on ty file for audit. Reverse Side. GNAT UR E: TITLE: DILHR SBD 6710 (R.01/82) I w,,-corlsln APPLICATION FOR SANITARY PERMIT s~ a. a DILHR COUNTY oePggTmenT oc (PLE; 67) UNIFORM SANITARY PERMIT # InDUSTgV,LFBOq 6NUTgn gELgTlOnS ~j /~~4 , i -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 PROPERTY O NER MAILING ADDRESS ZDaAee f AISfAl C/a s. 1?,7.Pf6-1) 6WA1 AP. 1f1.0,JX >,41UOSoo Gv/ . PROPERTY L CATION q C T"f- N9- 1/4 N'31/4, S 1.3 , T N, R l~E (or TOWN O ~lu~S'ON LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, T TATE PLAN I.D. NUMBER s r. P,POi r s7,f 7-10 Al s r- N - TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: =XEJ Public (Specify): THIS ,PERMIT IS FOR A: 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. 20 Seepaye Bed ❑ 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 /V Holding Tank capacity 4ZA Manufacturer: S ,e - ~ / ~rQif1 _07-37 IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ' Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): P,R/OPOSED(Sg7are Feet): f • , ?),0 Z7 ~ 5_(g u Private ED Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plum ftMFSITE)~EPTIC PLUMBING CO. Signature: ' ~'f~( ~Z~/~ I~ MWMPRSW No.: Phone Number: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 ~ 33o7 N e& Al( ?S Plumber's Address: Name of Designer: WIS. MASTER PLUMBER LIC. NO. 3307 MAR.& COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved O~~ l ❑ Owner Given Initial 144 Approved 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 1 INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.) ; 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 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/contractgz,("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 DA L F- 30HAIs0 'J Location of Property SF- - SW Section 12-J3 , T Zg N - R ~O W Township u, g 5'0 Aj Mailing Address )&4 DS Subdivision Name ST C©IK S~A-1 ~0~ Lot Number T Previous Owner of Property 55rM~6e-g d- 5Tf321e Total Size of Parcel A-PFeQ k $0 hee9S Date Parcel was Created 7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec Louse) ? Yes No Volume_ and Page Number 38 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) eeAti6y that aU btatementa on :th.,z 6oui ahe t.ue to the but o6 my (ouh.) hnowtedge; Aat I (we) am (ahel the owrteh(e) o6 the pnopenty desckbed in this in6onmati.on i6mm, by viAtue ob a we ari,ty deed ~cgcolcded in the 066ice o6 the County Regiz ten o j Deeds " Document No. yJ7 (o L70 and that I (we) pneben ty oun the pAopobed -6 to bon the .5eouage pos .6y6tem (on I (we) have obtained an e"emen-t, to nun with the above desc&, bed prcopeAty, bon the constAuc ti.ox ob said .system, and the bcuiie hos been duty neconded in the 066ice o6 .the County Regis,ten o6 Deeda, as Doewnen-t No. 1 . tom, ~,1~rti~ SIGN U OF OWNER S NATURE OF C -OWNER (IF APPLICABLE) ~ DATE SIGNED/ DATE SIGNED. 9'L~~ H :G N r-J y STC - 105 r H SEPTIC 'LANK MAINTENANCE AGREEMENT C St. Croix County OWNER/BUYER DAL J0 14A] ,500,) rn ROUTE/BOX NUMBER Fire Number olarr CITY/STATE HUDSD4) _ZIP S PROPERTY LOCATION:&9 5 LO 14, Section__Iz_!, T 2,9 m, it _LO _W, Town of_& St Croix County, SubdivisionSteeO1+C STATIoa , 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 LnmLer. What you put into the system can affect the function of the c•ptic tank as 'a treat- ment stage in the waste disposal system. St. Croix County residents maw 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 requiremc►lt 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 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the-standards set forth, herein, as set by the Wisconsin Depart- ~a 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. SIC N E D DATE p St. Croix C:,unty Zoning Office P.O. Uox 98 Hammond, WI 54015 715-75 6-2239 or 715-425-8363 Sign, date and return to above address. . v y = n m O vi phi ~ ~ w ~y y ro3 O ' ~ 1 1 ~ p 7 W 0 O- V9 O C W ~1 y 7C .m. C 0 c 3 mrc Z o O cD o a cD cD p P. C (D y m r+ y d1 ~ ~ 1113 .n_..w. ~ ~D N U01 C y :3 CD 0 CD 0 =r CO w ,yam -0 300 Cc- ~y Z = cl< .Q0 w cD w w y y - W o ~ ~ o -moo a~ D 17, to cr v CD N~ oDc-cam G) 0 n -A) n a C m '20 9aof w ' C N o~~ y fvA Z t N sw :E A" to C7 a CL (D 0 3 co 0 (CO, (=b (A w r. =a =0 =6 m -C 06 CL co R (A 10 ~v 3w0 -0CM~p'~z m r w C? p d to a yam w g: _ 0 "N "60 v, 0-= (a ~ =~~c a °D D 1 1 n C C7 0 E, CL CL m a cr C) co r to 1 co O 0 0 . CD (D 3 • A 0 y C.) (D O 7 s d0..a cf"w CCD -+MC(D a c a 1 a= O 0 7 3 C 0 p -3 O w a y a m ~ o ~ 3 CD CD D INDUS-CRY, ENT,OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, ' DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 539069 HUMAN RELATIONS (H63.0911) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP LOT NO.: BLK. NO.: SUBDIVISION NAME: Nr 1/ 1/ i3 /T 27 N/R1o E co ~/u056 / sr• c of X S7-47-1oAJ COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: 51, a-o i X ~A /F Jo h/N.Io.v % S~fE~P~-t P27~,G+ fo GA/~ ti~f v ,P1~. /V o . ~fo J USE DATES OBSERVATIONS MADE NO. BEDRMS : COMMERC AL DESCRIPTION: PROFILE-DE-SR! RIPT10NS: ER LA ION TESTS: ( Residence 4/ [-]New ❑Repiace I U! Cf• If Q 0c/ RATING: S= Site suitable for system U= Site unsuitable for system SC S CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) .2-dl l' ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ~NvE,~riov.►-L v.~'~i~F~~o E If Percolation Tests are NOT required DESIGN RATs~E: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: s s F7- • Floodplain, indicate Floodplain elevation: RM - PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (S E ABBRV.ON BACK.) p q } p . S' aes, 4,v%c D~ a N . L -S , 1 • -&Y. IS, • s B- b • y / f 1 Z 6 •.s- L 13P I -S S ' d~P- yr.~dQ . SA ~u D o.e 6:,4A I*c- -5 AAA - G s 13- 2.3 4 A3 - 6-y B-~3 S ,s , 7.2 B- J o ' 8714 A-- > y so as IS, - a- , CAO. e , BSS d 9y~ > 7d ' 6,, a,~s N,~c , s 6Af, 13- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERT D 2 PERIOD PER INCH P- 2- 2 2- P- P_ Zr- 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. x/0 TEM ELEVATION FT SYS { III ♦ 1 I ' 3ff a ( - r r _ , Gi~VF 60 w. I ~6'~ 4~7 / 3 ( 6Jl /33 16 _ _j 15- 04- ~-e+c i 5.~ ~es i - I O ~3 L_ 1 A4. pER ~'F. I C Kk47TL Gw ST I- . r- 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): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLET D ON: RT. 3 YNEIL RD., HUDSON, WIS. 54016 OG / 6 ADDRESS: CERTIFICATION NUMBER: [PHONE NUM~g (optional): WIS. MASTER PLUMBER LIC. N0.3307 OR& SS ` 8L `qL_ 3 C NATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER I 7 i S To O anc3 CROSS ~ ~~s 3?-/ P~oT SarjoN PIANS ~AST" God live, 6 6 4 .yob • I 35 s' 3 ~ I 1 I~ 1,40t ' P~Pa 1~~T -De-ee, [off- ~i.M.sro.~• S-f aT 1'0 A-1 K9*r-rq C, L) cuo ~MESITE SEPTIC PLUMBING CO. 7~ RT. 3 O'NEIL RD., HUDSON, WtS. 54016 LiCE~/SE ~ ROBERT ULBRICHT Wt 3307 M.P.R.& Z71- 7-,,-- MINN. INSTALLER & DESIGNER LIC. NO. 00663 aG-(-/I- Fresh Air Inlets And Observation Pipe soiL TesTIag By HOMESITE TESTU NG CO. Approved Vent Cap RT.-3, OWE1L RCo HUDSON, WIS. .1,4016 Minimum 12" Above Final Grade 'r1V 1Y"''e'Q M~X,M 4" Cast Iron y Z Above Pipe Vent Pipe i o Final Grade Marsh Hay Or Synthetic Covering min. 2" Aggregate Over Pipe Distribution Tee ~s•~ Pipe 0 0 0 0 ('P" Aggregate O Perforated Pipe Below to Beneath Pipe O Coupling Terminating At Bottom Of System _i