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HomeMy WebLinkAbout022-1061-40-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER nn ADDRESS 11 z 3 SUBDIVISION / CSM LOT ~ W Town of SECTION. , T~ N-R A 0 /l C r , ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM e 1 r ;;,oiioP ttki ~0001~~5 t'au'Ce ynk ~G I ew "atiA - c~w~Se~ ~C Exis ~nC~ l~000 ~ I can e d o ~ ~ hs sec fie 160.0 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 5 4 Stair -e t)elgL ALTERNATE BM: SEPTIC TANK JJ/ PUMP CHAMBER / HOLDING--TANK INFORMATION l Manufacturer: Ae-diyes'~ Liquid Capacity: //1vC% F ~0 Setback from: Well House Other Pump: Manufacturer (~oit ld Model#3M5_ Size /.j C/ Float seperation Gallons/.cycle: Alarm Location 4 I`7 SOIL ABSORPTION SYSTEM Width: d g Length Number of trenches 4~ Distance & Direction to nearest prop. line: 0?u Setback from: well: ~,^)o© House Other ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATIO : PLUMBER ON JOB: &V,) jI LICENSE NUMBER: R INSPECTOR: 3/93:jt L;part,dtTrNIC 21.28404EiVAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 199926 Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: zaj, TANK INFORMATION EL VATION DATA A9300325 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ?f k a ~-D 0 Benchmark /0 90 /00 Dosing Aeration Bldg. Sewer Holding St/Ht Inlet ID,jq q.2,6,t° TANK SETBACK INFORMATION St/ Ht Outlet !D; Q~3 I TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >a i 75' " 0 NA Dt Bottom / 7q•79 Dosing r 7 qJ NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System v, 9 PUMP/ SIPHON INFORMATION Final Grade I Manufacturer Demand o k V /3,03 Model Number GPM TDH Lift Friction' System TDHI ) Ft HHe Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS a,.q DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: G ? ~v 170 }a-d 0/4 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) ( Ld x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. ? Spacing / ✓ >Sb SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over dd K Depth Over aa tf xx Depth Of f- xx Seeded/ Bedded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil b ~fes I-] No [ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: KINNICKINNIC 21.28.18.P331C a t' _ , t Jl~ Plan revision required? ❑ Yes ~No / Use other side for additional information. 1/7 SBD-6710 (R 05/91) Date r` kpector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: f. t J SANITARY PERMIT APPLICATION -9,0ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY SAN ZdLs -Attachcomplete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. 1:1 cn i rev siapplication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO1 rY WNER , PROPERTY LOCATION T N, R E (o W PR P R R'S MAILING ADDREV9S LOT # BLOCS Cr C STATE . ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY 9 I NEAREST ROA ( ) State Owned VILLAGE ❑ Public ~'I or 2 Fam. Dwelling-# of bedrooms PARCEL N 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/Facto 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) ((~~1I ~ Replacement 3. El Replacement o A) 1.0 New 2. I of 4. El Reconnection of 5-E] Repair of an System System Tank Only Existing System Existing System 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 30 ❑ 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 VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE S Y STEM LEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSE . (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 6 o e7 1010 / 3 < ( (r ~G~C~ • Feet Cl • & Feet VII. TANK CAPACITY ite in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete C - S glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank X -I- W Li I Li Lift Pump Tank/Si hon Chamber U S~<> -TT ,,-j r36 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on ched plans. Signature: (No tamps) M Business Phone Number: Plum is Name (Print): P 3,03 Z, & - Plumber's Address (Street, ity, Sta e, Zip Code): i4z IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (Np Sta ) pproved ❑ Owner Given initial Surcharge Fee) A (7fi Adverse Determination I ~ Oyu X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: U IV SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & 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 thi permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit 1'rransfer/Renewal Form B[) 6399) to be submitted to the cc.mty prior to installation. 5. Onsite sewage :,y - t€ms must be properly maintained. The tank(s) must: be-;: rn -d Icy a•licensed pumper whenever- necessary, usually every 2 to 3 years. _ 6. If you have questions concerning your onsite sewage system, contact your local code :administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. . To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwellirg. 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. Vt. Absorption system information. Provide all information requested in ##1-7. VII. Tank iil4vr±7iat;on. FiII in the c,apa( ty u! e,.r ry new and!ci t.,x ank, ;st the total gai!Ds z !)UMber of tanks and rrianufacturer's name ifiaicvto prefab or site constructed and tank metui t al, Ccrn~~iste lot- all septic, purr p/siphon and holding tariics for this system. Check cyperimea ;al approval only if tanks received exper;rrjer,'.::ai product approval frc srl DII.t-H. Vlll. Responsibility statement. Instailinc., plun=ker is to fili in name, license nurn!)er with apnrc)r)ri-a(e 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 ;)'ans and specifications not smaller than X12 11 inches m., :f he submit_ed to the county. The . ^;rin r'-1 i include ft':er rctir,,v~irzg: A) plot t0 scale or 'rdlih Ji r flrilerSll tis, ;ocation of hokliog '.ar?k(s), Sept i.ar ;s) or other t e<_t <a 'arks; building c:•,'✓Ic:;S ,-l water mom:..:. vater service; stfeaT~~s and lakes, purra~ W ~iuhon tanks, c+i~+=ii~~~tian boxes, sc ii systems .pr,!ac >.r77ent system areas, and the locaii()n of thF: huilding sera?(! ^f~rizonta' an;r ls,,~ation refarenCe ':,OiPnt:i; C) complete specifications for pumps and cortro`.s, Jose volume; !yli vat _an differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (tees) for a number of regulated practices which can effect gioundwate. The ; oiJes co! ected through these surchargE . o;,C Cd f :r *.)n,'.c: c:ur7v- water contamination investigations and estate t~arr. nrc, - gill SBD-6398 (R.11/88) µM t 893 41183 Rae 31 if 4/,3w / 3a 31 N vi vi 93 ~y~18 3 E,t s~c~ Re~~ ~w ~~re ~6 ~9 93 sAF~'' & ~d e 12i~er ►3~S no , we11~ s•~1• ~oo,u 3-IJrq toe //S 1,0 Ex1, r~ Sep~'iC fob --o L N~7~a ga pun, C~ambrr ~ v 7RY, LABOR & ;4SEEOf COR A Top ~emed Slab of Ser viee Doer o' Cara e a= ~~e Niles yo A~Ue ~a.u'ce page - ' S-9, 41, R Straw, Marsh Na Synthetic Coverin~ $ 19~j3 ~C 2 Distribution Pipe Mirdlum Sane! Topsoil :[G I-~v. 4,ti: V _--1~+D(~l ' I) I T or`'~\Jp!. P `~`'~y ~:yA Ys ~,M :,~aLii_.-..~ +■1 _~,.,f..Y. ~ti{`_l~--J.1-Y~.~7.i. ~J.i3f..y`V ` k t "K Slope Bad of : . Q^ 2 2 Force Main Plowed Aggregate from Pump Layer a''~~vr of D _ 1.0 Cross Section Of A Mound' Systern Using E A Bad For The Absorption Area F ~S G Signed: H - d y7 ft. License Nuii,be r: 307-- I _ I Ft. Date: J ~ Ft. ? 3/1 K Ft. Mt~~`~ye Position of V t ~e7 Ft. } Force Main ' W Ft. J Observation Pipe ~P--- w I Fp~ce tin ~-j Prom Pump DiS;ribution i i • Pia Dbd Of i - 2 i I P Aggregate Observation Pipe Permanent Markers Pion View Of Mound Using A Bad For The Absorption Area ~ ~ .~S93 41183 Page Of y %0 l 0 C1 2 g A993 Perforated Plp• Wall S, OIV• SRF~N & SLOG n End View End Cop )Pef totaled r" i• PVC Pipe a' Holes Located On Boltom, S Are Equally Spored A i Q PVC Force Main 1 Q I0-Y WauE t4EXT 'm TN- M,~.11.mb pislribulion Pipe LeLl i4ose Should Be Ni.l To End Cap Diiiribution Pips Larou---t P S - Ft. R S 3• X Inches Signed: hole Diameter J, Itich License Number: 'Y 3 3 La Feral lL._ Lich(es) r7Y/ Manifold I n char s V Force Main Inches # of holes/pipe Invert Elevation of Laterals pq, ft. r OF INDUS7BY E7Y AIiD Ji~ in'a y (.r ~ ' COR a PAGE OF PUMP CHAMBER CROSS SECTION AUD SPE FICATIOWS v~~~~ S 9 3 41 18 3 vc WT CAP 0~.~ 2 ~ 1993 'i"C.I. VENT PIPE PROOF ~pGS• p~V APPROVED LOCKIN) WEATHER. JUWCTIOAI BOX MANHOLE COVER W~ 25' FROM DOOR, Wc~rrli/l~ ~~ctbr-~ WINDOW OR FRESH It~M11J' AIR INTAKE I GRADE I y" MILL Jl- I I 19" Mlll. COWDUIT 18"KIAI. IAILET PROVIDE I AIRTIGHT SEAL f -7 I I I APPROVED JOINT A I III APPROVED JOINTS / r ; wi I ( ( /C.I. PIPE W/C.I. PIPE i- I I I ALARM EXTENDING 3' EXTENDING 3ONTO SOLID i01L ONTO SOLID SOIL " I I I ow C# ~ t LLEV. 'Z- FT. N?iS __J I?1~ui1S7I1Y, LABOR S PUMP-~ OFF t r 0 Iyl~{Sit7N t!F SAFELY A BETE BLOCK SE 54 /j i 0 T APPRov RISER EXIT PERMUTED Ly F TANK MANUFACTURER HAS SUCH APPROVAL I asooNG SEPTIC E SPEGIFICATIOUS 005E liIC~bJt°S7 7r~4 j~ MUMBER OF DOSES: PER DAa TANKS MANUFACTURER: TAWK 51ZE: 7450 GALLOWS DOSE VOLUME INCLUDIWG BACKFLOW: GALLONS ALARM MANUFACTURER: i0, MODEL WUMBCR: CAPACITIES: A= G SL_INCHE5 OR 2C GALLONS SWITCH TSPC: j L B = INCHES OR GALLOWS PUMP MANUFACTURER: INCHES OR 1 GALLOWS MODEL WUMBER: D= _INCHES OR - ~ GALLOIJS SWITCH TYPE: t°`yr 1JOTE: PUMP AWD ALARM ARE TO BE MIWIMUM DISCHARGE RATE ' GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AWO 015TRIBUTIOW PIPE.. * FEET + MIAIIMUM NETWORK SUPPLY PFLESSUKEE FEET ♦ 50 EET OF FORCE MAIN X 2!~ LF/oof>:FRICTIOU FACTOR.. FEET TOTAL OtiWAMIC. HEAD = FEET INTERWAL DI STOWS OF TAWK: LENGTH ;WIDTH- L.LIQUID DEPTH SIGIJED: LICEWSE IJUMBER'. . DATE: 3~'3 SAFETY & BUILDINGS DIVISION ' I I State of Wisconsin Department of Industry, Labor and Human Relations October 29, 1993 2226 Rose Street La Crosse WI 54603 WANG EXCAVATING W9672 770 AVE RIVER FALLS WI 54022 RE: PLAN S93-41183 FEE RECEIVED: 180.00 MCLAUGHLIN, MIKE SE,SW,21,28,18W TOWN OF KINNICKINNIC COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50 64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. II; Sincerely, i Gerard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 2424R/ 1 SHI)•6423 (R. 0"1) S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Ali AP ADDRESS ( e l~ AC d f FIRE NUMBER CITY/STATE_r(,Der I 1 J,;- Z IP_ ~ PROPERTY LOCATION Sf 1/4, ~ 1/4 , SECTION-,-;)T d k N-R-21? W TOWN OF_ St. croix'County, SUBDIVISION , 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 needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. 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/Ile, 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 must be completed and returned to the St. Croix Co. Zoning O ficer within 30 days of the three year expiration da e.n r SIGNED:,,/, DATE: ) St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 STC-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 ~n delays of the permit issuance. ,Should this development be intended for resale by owner/contractor,(spec house), thenta 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 r Location of,propert ~1/4 1/4~ Section 5 ._L. TN-R, ~W Township Mailing address Pi- Address of site subdivision name Lot no. other homes on property? yes o ,I Previous owner of property Total size of parcel Date parcel -was created 'Are all corners and lot lines identifiable? `_L1__.Yes No is this property being developed for (spec house)? Yes ~LNo Volume~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 ',ffice of the County Register,of Deeds as Document No.~~ and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly record nV. office of County Register of deeds as Document r l, 1gnatu a of a licant Co-applicant ALA Date of sig ature Date of Signature. Nw 200 W-ty Deed-To Hueband and Wife AS Joint TenaCte. BubUsbao by Aau Claim soots dt&UODG V Co. 31047d This Indenture, Made this z5--t4- day of nit y .1972 , between Floyd McLaughlin & Mary McLaughlin part ies of the first part, and Michael McLaughlin & Diane T. McLaughlin husband and wife, as joint tenants, parties of the second part. Wttne0$ttD, That the said part ies of the first part, for and in consideration of the sum of .One and 00/100 ($1.00) and other valuable consideration Dollars, to them in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, have given, granted, bargained, sold remised, released, aliened, conveyed and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate situated in the County of , Wisconsin, to-wit: A parcel of 5.01 acres Located in the South one-half (S2) of the Southwest quarter (SW4) of Section Twenty-one (21), T 28 N, R 18'W, further described as follows: beginning at a point on the north line of said South one-half (S2) of the Southwest quarter (SW4) a distance of 31.1 feet east of the northeast corner of the southwest quarter (SW4) of the Southwest quarter (SW4) of said Section Twenty-one (21); thence North 890 16' West 250 feet, thence South 660 54' East 872 feet, thence South 890 16' East 250 feet, thence North 000 54' West 872 feet to point of beginning; the north 33 feet being used for town road. TRANS I i__'fl I. W Zoget§er, with all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. Co I?abt an0 to 1?01b, the said premises as above described with the hereditaments and appurtenances, unto the said parties of the second part, as joint tenants. An0 tot ftib, part ies of the first part, for themselves, their heirs, executors and administrators, do covenant, grant, bargain and agree to and with the said parties of the second part, and to and with the survivor of them, his or her heirs and assigns, that at the time of the ensealing and delivery of these presents they are well seized of the premises above described, _ DEPARTMENT 6`US-R OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IIVDUSTFtY, DIVISION LABOR P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 LHR 83.0911) & Chapter 145) LOCATION: pp SECTION: p,~ TOWNSHIP UNICIPA TY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 3 E11 J UIJ~~ a /T 1 ~0 1~/1V &-E (or ' COUNTY- M LI G RES : J e r Or. k'J'uer USE DATES OBSERVATIONS MADE NO. BEDRMS.: ICOMMERCIAL DESCRIPTION: PR D S: T STS: 'Residence ~ ❑New Replace RATING: S= Site suitable for system U= Site unsuitable for system G ROUND ~ OEM-IOU L HQ SG❑t . RECO~ApIJ~~~D $tYSTEM:(optional) -PRESSU O STIou ONAL: MN SOUND: 11U IN-G11 S QU RE: ISYSTS If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: 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.) ~I B- ) to 1J 3 JJ ® -),v 15 v 6 it 9 m f A(f S Gu rd &.4 'fir B- S ~r d ( it B- fl , / 5 J Jl J II 0-9"/r S it F, S lv B- B- 6L" q~ DS y 3 I 6_8"61' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. pERI DF_ 1 PERIOD2 PERIOD PER INCH P 0 ~0l 6 / /11/1 P- U It l p- tl ! 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 q~, 2 " j 1 114 r t 111 ~ 1 r 4A f7 i E U I s v1 tak, T__ -lift ~A/ 3 I mm-; 1 ( i 1 1 ~ ( i3 t ` L 1 1 i 0 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures an 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 OMPL TED ON: ad'~ ~jR f? - 6 ADDRES : CERTIFI TION 14UMBER: PHO E N MB to ti nal): WOO 2Z 14m &er a CST SIG E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under T') LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well Is - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand < - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point 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. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING; .i4DUSTRY., DIVISIOP LA3OR AND PERCOLATION TESTS 115) P.O. BOX 796' HUMAN RELATIONS MADISON, WI 5370' 090) &'Chaipter 145) 3 LOCATION: SECTION:- p ~TOWSHIR UNICIPA TY: LOT NO.: BLK. NO.: SUBDIVISION NAME: 1 J 0/4 0 /TaB'M/R)$ E (or = COUNTY t M LING S I I USE it; ,,DATES.OBSERVAT.IONS MADE NO.BEDRMS: COMMER ALD S RI TION: TS: Residence 3 ❑ New Replace RATING: S- Site suitable for system . U= Site unsuitable for system ONVENTIONAL: MOUND: N-GROUNDRE S-UR : SYSTEM-IN-Fl LL HOLDING TANK: RECOM ENDED YSTEM:(optional) ❑ $ ❑U NS 00 ❑ $ ❑U ❑ $ [:]U $ pct If Percolation Tests are NOT. required DESIGN RATE: I If any,portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEW H TO GR UNDWATER=INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B I b~ i` r ► 6 ,f 0-aly` 6 15 v„ ' 6 6" B M Fn S IV jqrd B- 5y, ~ cis f 3 t( B-~ 3 b I I -a F~'y F' S tv B- a'fie a-s 6 B- 3~ f I 6-:8`6 f ( fin`;. 11" In Fin JV r B- W 4,"tt 5y od s a 3 b PERCOLATION TESTS TEST DEPTH WATER.INHOLE TESTTIME DROP WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN: PERIOD 1 PERIOD PER INCH P- rl D a p, P- yr` d / P- tl 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 percen of land slope. SYSTEM ELEVATION 99 7~ e 1P e r ` Z lid - a 10 re q& e U L° I y IZ- B-Z 1~0 re CL. - ~o I, the undersigned, hereby certify that the soil tests reported on this form were mad by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the locatiion of'the tests are correct to the best of my knowledge and belief. NAME print TESTS WERE OMP TED ON. 6 ADDRES : CERTIFI TON UMBER: PH N MB (o ti nal): t CST SIG E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER -