HomeMy WebLinkAbout030-2042-20-000
AS BUILT SANITARY SYSTEM REPORT
OWNER. I ,^,e61111 TOWNSHIP Gzl-
60, SECTION 2~ Tr~N-R -Z W f~
ADDRESS ST.rCR IX COUNTY, WISCONSIN
SUBDIVISION LOT e-=-LOT SIZE--
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
A
~f .27,
- - - IVY
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: der p ~'~C~
Alternate benchmark 'TD oT
SEPTIC TANK: Manuf acturer : Liquid cap. o-a-d
Rings used:'"- Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
r
No. of feet from nearest road:Front , Side, Rear Ft.- b
l
From nearest prop. line:Front , Side, Rear Ft. a
No. of feet from: Well 4M t'~ , Building: l~
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I,I
J
1
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/$iphon Manufact.: Pump Size
Elevation of inlet:- Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front_, Side_, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width:Length Number of Lines:_ Area Built
Exist. Grade Elev. Ste' Proposed Final Grade Elev.
Fill depth to top of pipe: j~
No. feet from nearest prop. line:Front , Side Rear Ft.~?V
No. feet from well: No. feet from building
14-lzot
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE : PLUMBER ON JOB : .
LICENSE NUMBER: 3 ~l
6/90:cj
i
' L A;W1Wp;,tm eTritof4T9 H 26.30. ?%jj Jg SfWk6E S TE W E County:
Labor and Hu[nan Relations INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village R Town of: State PAW:,
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/O C?, U /00.0
TANK INFORMATION ELEVATION DATA A9300017 30 /30
OA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic u ,7 Benchmark lp3 ~~D
Dosing (3 1')
Aeration Bldg. Sewer
Holding St/ Ht Inlet qcj, 7
TANK SETBACK INFORMATION St/Ht Outlet 6.~ 9 y. y
Verit
TANK TO P / L WELL BLDG. Airintato ke ROAD Dt Inlet
Septic A,0 r /7 NA Dt Bottom
Dosing NA Header / Man. g, c~8 9 S , Z
Aeration NA Dist. Pipe 8 3~ c7S, 3~
Holding Bot. System 9 q,q j
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand N- 7 q~- -CA
Model Number GPM
TDH Lift Lr' tion Syeaem TDH Ft
Forcemain Length Dia. FFii Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION S DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER q ,~f / O , Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pi e(s) {1 x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- I Length 5_1 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center ` J, Bed/ Trench Edges > `f Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) 41
LOCATION: ST. TOSEPH 26. 30.20.493B,NE,NE, CO.~ E
Plan revision required? ❑ Yes [~No 1
Use other side for additional information. 3a"
SBD-6710(R 05/91) Date Inspector's Signature Cert.No -
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ,
SANITARY PERMIT APPLICATION
DL~.HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
z ST SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than /f Q3~(C~J
8% x 11 inches in size. 1:1 Ch/l f revision to pr~vious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTYO R PR PERTY LOCATION
aCe
S 91~ T N, R O E (or
PROPERTY OWNER'S 4AILIN ADDRE OT # BLOCK #
r 3
CI ATP ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
1O / ~ ~ O r2 ,4 -21Y
s9r:c /
II. TYPE OF BUILDING: (Check one) .rte NEAREST ROAD
f~ ❑ State Owned ViLTML.AGE :
❑ Public LLJ or 2 Fam. Dwellingsof bed 2u
rooms EL TAX Nu B ( )
0
111. BUILDING USE: (If building type is public, check all that apply) Q
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
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 Reconnection of 5.0 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 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
I oa 7,017-0 i 6 .2 ,r /A Feet 7 Feet
L-1
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank _2S+_ Z42?2
Lift Pump Tank/Si hon Chamber
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 Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number:
e rl g l .26 ?
Plu r' Address (Street, City, tale, Zip Code):
w
IX. COUNTY/DEPARTMENT SE ONLY - /011
❑ Disapproved 1,5anitary Permit Fee (Includes Groundwater ate ssue L
Adverse ng Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
G
Determination 7 6 r,,.
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
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 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 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 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 dine 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 DILHR.
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 13'% 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 form; 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.
SBD-6398 (R.11/88)
FLUT PLAN
PROJECT_ C~t ADDRESS
j S 1/4 0 1/4/S0X/T~O N/R,~W TOWN COUN
Byron Bird Jr. 3118 DATE
BEDROOM CLASS PERCCONVENTIO A _ IN-GR 6t~g I'
PRESSURE
CONVENTIONAL LIFT- MOUND-
HOLDING TANK
SEPTIC TANK SIZE .V-ap-= L
IFT TANK SIZE
~2
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE e 3 BED SIZE /51 X cwt
► Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark 14? 7
H.R.P.- - s'~ Go.~~s er o~,
O:Borehole- Q Well Scale Feet
O Perc Hole System Elevation
Uent
12"
Grnde
l
TYPAR COVERING
2"
12" 3' 4 6' O 3' 3' 0 3'
I 6" Sewer Rock
i 12' 18'
~o _t4( sx
ti
t(7 O fit(
101 eh, I
r
14L
y4
Y
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
N
INDUSTRY., C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
N WI 3707
HUMAN RELATIONS
` (ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: CWZNSH~UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
1/ e14 I /T ON/ tf I. t osp ~i
_W -
COUNTY: MAI LI G AD ESS:
SfGr~~~ OCL 0 c
USE DATES OBSERVATIONS MADE -S^
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER ION TESTS.:
I Residence ~ New ❑Replace
Ina? 5-Az
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
rRS EU [S❑U SOU ASCU ❑SZU o
If Percolation Tests are NOT required DESIGN RATE: 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 BSERVED (SEE ABBRV. ON BACK.)
B- 11911 _e*7 11:517~.12
/Y 4,
B-
B-
PERCOLATION TESTS
TEST 'DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P 1003 PER INCH
P_ G
P-41
P-
P-Loe
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
t Sly
~ t
9
oel
G v
04 L
u
401 -e-
~~.L or watt sf~~' N
~o a~ s
5
o~
L
q0 ►I
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:
7 fir. -
ADDRESS: CERTIFICATION N MBER: PHONE NUMBER (optional):
rn ~r _ '5 as - 7E1
CST SI N E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER v T
vrf
ADDRESS: / / y i -,I71A -W FIRE NO:
LOCATION:-- _1/4, ~1/4, SEC. _G T_262 N-R~C~
TOWN OF: ST. -CROIX COUNTY-,-'
SUBDIVISION: LOT NO.
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 to
help with the cost of the 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 the St. Croix County
zoning 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 (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification from will be sent approximately
30 days prior to three year expiration.
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 form must be completed and returned to the St.
Croix County Zoning officer within 30 days of the three year
expiration date.
I.
DATE:_
0
St. Croix County Zoning Office
911 4th St. -
Hudson, WI 54016
STC -loo .
This application form is to be Completed in full and signed b
the 01;11et (s) of the property being developed. An inad s
will only result in delays of the permit issuance Any Shou ldathis
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 k 1/4 1/4, Section
T;L0 N-RAW
Township
v,
Hailing address - ` -
2 .
Address of site
Subdivision name -
Lot no.
Other homes on property? es
Y -------N o
Previous owner of property
Total size of parcel
Date parcel was created
C- ~ ASS
Are all corners and lot lines identifiable?
_Yes No
Is this property being developed for (spec house)? yes No
Volume-, gnd Page Number
of Deeds . as recorded. with the Register
INCLUDE wITII THIS APPLICATION THE FOLLOWING:
A WARIUUITY DEED which includes a DOCUMENT NUtiDER, VOLUME AND PAGE.
NUIIDI R & 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
warranty deed recorded in t114 office of the CountY Ss Registeof a
Deeds as Document Ho._ Z9, r
presently
own the proposed site for the sewage di p salt system ) or preIse(ntly
(we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in t eroffice of County Register of deeds as Document
~5
Signature of ap~licant
Co-applicant
3-/- g-~
Date of Signature
Date of Signature
t
ti
d tts
-room 3
DATA
*T.
Rss",i►~ #i 23rd
'
DOC 0615 p
T.
f 7 J, z sl fJ •
1theWmiget & Rheinbelget
M•. 217 No. SeaOM St.
Mw k+lb~rrlglk~lMQd~►
aA~ Stillwater, MN 55082
th¢ QF the mEj of Ssatup Tu W Mw
tkot p of
A
f; 26,i3D_4 wbigb is E' of the Town Road which
a wily in at !i' ~y and s' ly directian rwac
s the "ation lift betireen Saetior 25 and 26, ~1 of
C"Wy Tr "E 1
A. a
,
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04 @a rAA
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19
ZfAL) C2 ui
r naavtrf a Hefty
IWTN[MTlCATIOM M~ WLILDOEMEMT
1h+s dot of #T,AT& 4FMM1~
WASHII+{MM Cotiatat
Pyraoelstt QMrll aMon aM. aAis 16th day of 17 0 8
TITuL MEIN! VATS "CW wo""15u++ tM aaow nrrn.d
V a OWM Aft David Arthur Hefty
: W WW 0044
7AIS ~ +eee a1#+~ ~
C f 14O_ St. to me w~ to be tMe polson wft woculed Ifto laragoIN M-
St li j r..M
f..:
tffi~p+W►t++ + 6 bl PBtr`inia b
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- wr ~11i1'CIFrIISH'~. tia
REPT131 St. JOseph ST. CROIX COUNTY ZONING PAGE 1
0.4/29/93 16:25 REQUESTS FOR INSPECTION WORK SHEETS FOR: 4/30/93 AREA: MJ
'Activity: A9300006 4/30/93 Type: CONV93 Status: PENDING Constr:
Address: HUDSON 14.29.19.96B,NW,SE, CO. RD. E
Parcel: 020-1021-10-000 Occ: Use:
Description: 186549
Applicant: FOX, KEVIN M & SHEILA A Phone:
Owner: FOX, KEVIN M & SHEILA A Phone:
Contractor: SCHMITT, DONIVAN Phone: 568-4948
Inspection Request Information.....
Requestor: Byron Bird Phone:
Req Time: 13-.#84 Comments: / 0~0 m
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
I
♦1
r Parcel 030-2042-20-000 02I11I2005 09:02 AM
PAGE 1 OF 1
Alt. Parcel 26.30.20.493B 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
ALBRECHT, DAVID W
DAVID W ALBRECHT
200 CTY RD E
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 200 CTY RD E
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 4.000 Plat: N/A-NOT AVAILABLE
SEC 26 T30N R20W 4A NE NE AS IN VOL Block/Condo Bldg:
307/447 THAT PT LYING ELY OF TN RD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
26-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
04/26/2004 760601 2556/529 EZ-U
07/23/1997 1110/043 QC
07/23/1997 728/624
07/23/1997 684/13
2004 SUMMARY Bill M Fair Market Value: Assessed with:
6071 194,600
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.000 92,400 99,000 191,400 NO
Totals for 2004:
General Property 4.000 92,400 99,000 191,400
Woodland 0.000 0 0
Totals for 2003:
General Property 4.000 54,500 79,800 134,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 211
Specials:
User Special Code Category Amount
~I
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DE,PARTMEN T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND 1 CC P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON, WI 53707
(ILHR 83.09(1) & Chapter 145)
U
LOCATION: SECTION: WNSH UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISIO NAME:
'/a /T oN/ (o o s p -
COUNTY: n J MAI LI G AD ESS:
StGrv~n ~a rJrC~ G S`/,r
USE DATES OBSERVATIONS MADE -
NO. BEDRMIS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: IPI=HL; O ION TESTS:
I Residence New ❑Replace s
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S❑U [~S❑U S❑U ❑SCSU ❑SAD o
D
If Percolation Tests are NOT :SIGN RATE: re wired If an portion of the tested area is in the
under s. ILHR 83.09(5)(b), indQate: /Gafj Floodplain, indicate Floodplain elevation: ~d
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 BSERVED (SEE ABBRV. ON ACK.)
O 5 o
a a- *-7
B-3
B- g' A,- - ziirc
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERI002 PER OD PER INCH
G
P-
P-
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
~ 70 0
A .1.51.
A, '-gA4
.2140
Ale
Wo ell"
V ~
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:
r '000'a '7 7
ADDRESS: CERTIFICATION N MBER: PHONE NUMBER (optional):
76~'
.3 V 7 59-
~c C~1 as
CST SI N E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
f
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 suction must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. 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;
6. 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 3") 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
'sI - 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.