HomeMy WebLinkAbout038-1085-10-120
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ULI,- oL n e Y'YY1 of 1
ADDRESS O?t 1 4)~ JS) O A
Sd er~~ , Wi, 0
Zo 3o C*,) L - Sonw-rS:Q•t
SUBDIVISION / CSM#_ QeA.yykQ , - LOT
SECTION a 0 T N-R__Z Town of
stct r T hu / b l
Zo . 31. 6?. 3s,+ A-Lo
ST. CR COUNTY, WISCONSIN
3 AAA raly- PLAN VIEW
SHOW EVERYTHI G WITHIN 100 FEE OF SYSTEM
1
4
~r
1
15
q ~
" IND CATE NORTH ARROW
W
Provide setback and elevation information on reverse of this -fox'm.
Provide 2 dimensions to center of septic tank manhole cover.
I
x
i
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION
Manufacturer: Liquid Capacity: boo
Setback from: Well- House 3 Other
Pump: Manufacturer Model# - Size
Float seperation Gallons/cycle:
Alarm Location A)
:SOIL ABSORPTION SYSTEM
r ~
Width : /,;Z Length 41 Number of Distance & Direction to nearest prop. line: ( - l 5
Setback from: well: A97 Housed Other
ELEVATIONS
Building Sewer .14Y. ST Inlet; 9 3 ST outlet 97.
PC inlet -PC bottom Pump Off
Header/Manifold Bottom of system 9.3•.S
Existing Grade 7~G-S Final grade 9/ .
DATE OF INSTALLATION: g _ -
PLUMBER ON JOB:
LICENSE NUMBER: 15 &-3
INSPECTOR:
3/93:jt
F I
XW,A=wpert`~T'eU8l.FiW, IE 20. 31. MvA"*AWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Saf(sty and Buildings Division
(ATTACH TO PERMIT) sanitar rinit
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI
X
ev.: Insp. BM Elev.: BM Descriptio Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300160 0
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing O tl .5 6J,
Aeration Bldg. Sewer
Holding St/ Inlet
TANK SETBACK INFORMATION St/of outlet 5,97
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic i' NA Dt Bottom -7~
Dosin NA HeaderT. 9 37'
Aeration Dist. Pipe
Holding Bot. System p SD
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand Z"
3 39 (1~,~7
Mod Number GPM
riction em H Ft
ift L
t
EDH] L
: -1 oss ea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Leng / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / D111AEN I
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEA NG Manufacturer:
SETBACK CHAMBE
INFORMATION Type Of /7r, o e Nu er:
System: 107 OR UNIT
DISTRIBUTION SYSTEM
Headerd- i~ Distribution Pipe(s) , Ix 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 xx Depth Of Pxx_Seeded /Sodded
psud ❑ Yes ❑ No E] Yes ❑ No
Bed /Trench Center G~6 - y Bed /Trench Edges To
COMMENTS: (include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 20.31.18.354A20
U
Plan revision required? ❑ Yes to
Use other side for additional information. 9 U(
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH ' . .
SANITARY PERMIT NUMBER: '
I
I
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
$-t Gro1X
STATES ITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ 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
CLIP In co •e r m (k ` v1 M J % S LC t/a, S 4!0 T.3/, N, R (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/ 0 /V n
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
sm-ftmit
II. TYPE OF BUILDING: (Check one) ❑ State Owned CITTMLAGE S~~ t wi NEAREST ROJ t i ii
TAX Nu aM
❑ Public LA1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL =N QF:
111. BUILDING USE: (If building type is public, check all that apply) Q 3 D ~S ' / /~[O
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash
50 Hotel/Motel 90 Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. P New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
ful
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
45 REQUIRED (sq. ft.) , PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch). ELEVATION
O aZ CJ a S m A /A C13, 5 Feet - 9 Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New lExisting Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank GC (A.)•Q..tYa t"
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 S' i re: (No Stamps) 7_114 PRSW No.: Business Phone Number:
C~ Ut A ld erg 7~r - -s✓ s
Plumber's Address (Street, City , State, Zip Code):
X'A"~ [,Jar s5~~/T
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signazure (No Stamps)
Approved ❑ Owner Given Initial 10 Surcharge Fee)
Adverse Determination I / ~U Q,.~
,
X. CONDITIONS OF APPROVAL/REASONS 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. Changea in :i,,vr.erst?;p or plumber requires a Sanitary Permit Transfer/Renewal Form (SBO 6Ke) to be
subrTQted to the c.ou,rity prior to installation.
5. Onsife-sewr~ jle must tie proper y maintained. The septic tanks) me, st becs purnpeid by a licensed
pumpe4r,whe-ever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code adilnMistrei or th4
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 numbers) of
where the sysldm, is to bet +nstalled. , -
11. Type of buildirg 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 pe.rrnit. Check: only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of systern. Check appropriate box depending on system tape.
VI. Absorption system information. Provide all information req,lesfrd in ##1-7.
VI:. Tank informati in Fiil _i the capacity of every new and/or t ti ly tank, list 1!,,e 10 1I i; iic7!ss number of
tanks and manufacturer's name. Indicaie prefab or site ccn~ eructed anc tank. -iia ;r,~;Li (oinf.;ete for all
septic, purr=c•/siphon and holding tanks folr this system. Check perirnentai apprrofai o !y !anks eceived
experirs,, ;-t,' product approval from DII)i
Vlll. Responsibility statement. Installing piumher is to fill in name, license number with appropris-.'e prefix (e.g.
MP, etc.), address and phone number. Plumber must sign ; fpplitiation form.
IX. County/Depart-ne-it Use Only.
X. County/Depart-ner?t Use Only.
Compete plan= a ..1 specifications not snialler than 81/2 x 11 im hes must hx r .+ttf d tt+ county. The
p!=ins mus- me _r"O'"o following: A) pact p=an, drawn to sc_'e. -r with coi-nplete & el,:; -m,., ocation of
holding tank s( , -enric ',ank(s) or other treatment tanks: i wafer service;
streams o.nd 1rycxc, ;,,rwnp or siphon tank;:, distribution boxes,o i.sofotior! ^3ys~e,o r ij,,;,,A1merit system
areas; an; 'oc. (.i of the building served: B) horizontal a.i:' poiP s;
C) complete: si:ec F ^a!ions for pumps and -ontrols; dose volume; -!1ovat,on difference:.;; r -cti,n loss; pump
performance oJrve; pump model and pump manufacturer; D) cross section of the soil absorption system if,%,
required by thin county; E) saiItest data on a 115`ferm; and F) all ,s ifig jnformatttln.
- - - - - - - - - - - - - - - - - -
GROUNDWATEITtURCHARGE
1983 Wisconsin Act 4117 mc!uded the creation of surcharges (tersl for a number of
regulated practices vvhic`1~ can effect groundwater.
The monies ooriectc;d `r.i,gh theRS gh ar;s srte used for rf,r tc i, gro I€idyvate r c
nc9- - -
wat6t~cfmtarniratro, it es? g~±rirns and establishaient of standards. .
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PLRMI'1
S T C - 100
of the
This application form is to be completed in full and signed by. the owner(s)
property being developed.' 'Any inadequacies will only result in delays of the permit
issuapce. Should this development be intended for resale by owner /contractor,("'spec
house"), then a second 'form should be retained and completed when the property, is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property n
TN-R~W
5,6F- fit. Section
,420 14
Location of Property
Al.
Y'
f9wnship
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property Gc )'11~
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? / Yes No
-
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number 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
Surveydelays
In addition, a certified. survey, ifavailable, would
tosa Certifiedavoid
referenceshelpful
of the reviewing process. If the deed description
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) eehti• y that aU statements on this 4ojun ane true to the best of my (oUM
know.Zedge; that 1 (we) am (ane) the owneA (s) o6 the pnopeAty desek bed in this
.injonmation Jonm, by vi tue o6 a wannanty deed neconded in the 06jiee o6 the
County Register of Deeds as Document No. S 2 ; and that I (we)
pnesentZy own the proposed site bon the ,sewage pos system (on I (we) have
obtained an easement, to nun with the above descAibed pnopenty, box the.
eonstnucti.on o6 said system, and the dame has been duty neeonded in the 06jiee
06 the County Reg•i.aten o6 Deeds, as Document No. - 1
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE'SIGNED DATE SIGNED
~I DOCUMENT NO. I STATE BAR OF WISCONSIN FORM :1-198211 THIS SPACE RESERVED FOR RECORDING DATA ~I
QUIT CLAIM DEED
Theodore J. Germain and Jeanne C. Germain, husband and _ RE BT~CnOlX CO., V11i~E ! II
wife, as marital__prop erty with rights..of survivorship 1
quit-claims to .Urban GermpinpandyPauline Germain husb~ p FEB 1 7 1993
and. wife,-- as marital ro ert with ri hts of survivorshi ' 8:30 A. M `
Register of Deeds
'
the following described real estate in S.t-.__-cI'O County,
State of Wisconsin: RETURN TO=
-
II~~ I
Tax Parcel No:
Lot Two (2) of Certified Survey Map, filed September 12, 1989 in Volume "8" of
Certified Survey Maps, page 2149, as Document No. 451474, being a part of
the Northwest Quarter of the Southeast Quarter (NW} of SE}) of Section
Twenty (20), Township Thirty-one (31) North, of Range Eighteen (18) West.
I
i
i~
EXEMPT
!I
~I
i
!
it
i
This ....is.not homestead property.
(is) (is not)
Dated this day of .....February. 93
~I
__(SEAL) /
- eodore J. erma
l
-
- - - . (SEAL) - - - - ----(SEAL)
' - .Jeanne C. Germain
AUTHENTICATION ACKNOWLEDGMENT
I)
Signature(s) STATE OF WISCONSIN !
County. .
St. Croix ss
authenticated this day of Personally came before me this
day of
kebxua_ry_..................... 1993.... the above named
-The odor e-.,Tom..-Ce=ain--and__Jeanne--C.-- I!
' -Germain - -
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not- - - - '
authorized by S 706.06, Wis. Stats.) -
to me known to be the,09rs6}I' _5......... who executed the
forego' instrumen eckii4wledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Reinstra, Van Dyk & Needha__m, S.C. r---- ; 1
201 South Kno~rles Avenue, Bo--- 127 - . Ruth A. Joins' '
4
N>:w 1tic~3mozd; WI 54017....... I
Notary Public $ - of g_cr _--_91 .County, Wis.
(Signatures may be authentirated or acknowledged. Both My Commission N pe c6t- 1If pot, state expiration
are not necessary.) 1'LJ 1$/ 94
date: 19
-
r..
I
i
QUIT CLAIM DEED STATE RAR OF WISCONSIN Wi--ia Loral Rlan4 Co. Inc.
FORM No. 3 - 1982 Milwaukee. Wis.
S T C - 105 r
r
SEPTIC TANK MAINTENANCE AGREEMEN'r ~
St. Croix County z
OWNER/BUYER
ROUTE/BOX NUMBER Fire Number d.3d
CITY/STATE S6rner ZIP
PROPERTY LOCATION: IUW ..7145 Z, Section ~?D , T 31 N, R I6 W,
Town of 'a i 4v , St. Croix County,
S7`'g Y r- ti
Subdivision Lot number.
I
Improper use and maintenance of your septic system could result in
its premature failure., to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix. County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (.if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
G
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 Depart- ti
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED ✓ c
DATE l0 ~~J
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
i
1 ~ I ' 1 ~ I i I t i , ~ i ~ i
L v
I ;
I ! I
CAJ
f
it
'pp
I I I
I I ~ I i(' j ''f~ t 1 I I i !
t
i ! I i~; I~ I{ I I I I' '
j J ~ 1 ~ I I , i I I j
}~t.lYys-}je,~c~r xlly-
j ae ~ S~►' I i ' 9
r >
j _ I I
1
I I ,
I
.40
q j
V I I I}{~ I I f I I I I I ~ I I j
II , ~
I i j I I I I
i
. 1
I t t , it + i - ~
i
i
I
U r Yr 4
PAGE OF
m~rse-~rvSyS~~Se~~I~n O~ en S y stems
~
Nw ~SE as -3/ - ~ ~
s~ar ` rW,r 1 L°
Froth Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade
20- 42" Above Pipe _ 4' Cast Iron
To Final Grade Vent Pipe
Mash Hoy Or Synthetic MiODistribution Tee
Pipe 6
BPerforated Plpe Below
-Coupling Terminating At
Bottom Of System
P~pPoSet~ ~Ina~ grac~c ~
~~cJ•:~ ion ~
12
SOIL FILL
DISTRIBUTIOU PIPE
APPROVED ~4MPETIC COVER
~'MATER14 OR 9" OF STRAW
Z" OF AGGR EGAlE OR JAARSM HAy
e °
V aF qs 3 to OF 12 -21/2 AGGREGATE
FEET
DI•ST1115UTIOM PIPE TO BE AT LEAST IAICHES BELOW ORIGIUAL GRADE
A►JD AT LEAST20 IAICHES SLIT 1.10 MORE THAtJ H2. MICHES BELOW FINAL GRADE
I
MMIMUM DEPTH OF EXCAVAT1mMI FRoM aRI&PAL 6RAoF- WILL BE IUCHES,
rJ141MUM W" OF EXCAVATION FKOIA C*14I44t OR49E WILL BE 3S." INCHES
SIGAJED:
LICEUSE MRABER: /563
DAT E : _7 i
Wisponsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of .3
Labor and 'Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but -1. C r o 1
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
h h C1 Y\ 6-:1 e- y- GOVT. LOT `ffW 1/4 5F 1/4,S 090T 3 / N,R / fj *or) W
PROPER OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
+ 1 (31 !2y NO A a N ~
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VI LAGE MOWN NEAREST ROAD, , ,
41
New Construction UseX Residential / Number of bedrooms .3 [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow !!~50 gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required &.2,5 bed, ft2 //Q 3 trench, ft2 Maximum design loading rate • 'y bed, gpd/ft2_~trench, gpd/ft2
Recommended infiltration surface elevation(s) 93.5 ft (as referred to site plan benchmark)
Additional design / site considerations , y Lo t.J.n.a114 Comma.. 5"
Parent material it ~ -A-W o s k Flood plain elevation, if applicable It
DR I
S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
S❑ U N S❑ U S❑ U ❑ S U E:] S 10 U ❑ S U
U=Unsuitable for system
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer&
ZOIZ& 2
Ground Q CS'C' ~ m I ~ ' y
elev.
ft.
Depth to
limiting
factor ~i
Remarks:
Boring #
D 2 t Yh flr- rr- 9
Ground C _S -4-4
elev.
% $ ft.
Depth to
limiting
fac or 7
Remarks:
CST Name:-Please Print s Phone:
r 7 _a -3/3.S
Address: '65 ~c S ya 7
Signature: Date: CST Number:
1
PROPERTYOWNER urb44vn c7ZI% ►')A.rr SOIL DESCRIPTION REPORT Page 6? of
_
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed Trends
n....,,_ . _ _ S /h us, arr. 1
Ground -3 *-8 b C d cJ /4
i
elev.
ft.
Depth to
limiting
factor
yY ,
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring # y..
Li
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
~ M14M1
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
- - -
• I 1 ; I
I 1Rhc]
I I i.
I
r I
I I I
I I I I ~ ,
04- y
I
1
14
1 ~I~ Y
I I I I `
I ( ! I .
41
I ~ ~ - I I I
1 - -
so,
I I
I I I I
I I
I I I ~ r i
I I I I ~ ' I i I I _J I I
I I ~ ~ ~ I ~ ~ I II I ' ; I I I I
1 '
I , ( I I ! I ~ ~ i ~ I ! , I i
I ~ 1 I I f
ice
i7 t&
I I ~ ?
1 ~ I I I I !
I I I I ~ I t 1 i ~ i I I
I C
I i j I' I~ f i l l ' I ~ ~ I I r l
C '
I I I 1♦ ' I i ' ~ I i 1 ; ; I I
,
,
,
! j ! ; I ; I i I I ~ i
,
, I
I
I I
I I I i I I I ~ _I . ' I
I ! I
I ~
i i
I i
i
I 1
r
I f
I
I I
I
.
' l
` I I
I ,
l- f a
r
~ I E r F ~ I
I j i. I I ~ I
I ~ l ~ j l I I
I
~ I 1
y i
I ~ I
I I I
I
- 1
I I I ,
I I I I 1
C
f
; ; I I I I I
I
I I
I t _1
I
I
I
I ~ ' ~ - I 1 -t I I
_ I
I
_ ~ I I I
1 1 1 1 1 1
I
I I j ~ I
I '
I
T
I
{
I I I ~ II
I '
; I I
I I I 1
} 1
1
I I
I
i I
. II 'I i I - i ~ 1 I !
I I I
I I 1 I
r-
I I I I ~ I
I I
T
L_
t
I
1-
I i I ~ I I I i
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IIyDUSTRY; DIVISION
69
_LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707
HUMAN RELATIONS
83.0911) & Chapter 145)
LOCATION: E OWNSHIPI UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME
Ald 1/ V4 /T3 NM E (o r
COUNTY: OWNER'S/BUYER'S NAME: MAI LINUIE%SS:
$
wlSG 5 r
I let 10 1#
4~ I^
USE DATES OBSERVATIONS MADE
Residence NO. DR COMMERCIAL DESCRIPTION: DESCRIPTIONS: IPERCOLATION TESTS:
New ❑Replace I ~ I _ry. / -
RATING: S- Site suitable for system U- Site unsuitable for system
ONVENTI NAL: MOUND: IN-GROUND-PRESSURE: rYSTEM-I_N-_F_I _L_LJHOLDI NG TANK: RECOMMENDED SYSTEM: (optional)
$ ❑U $ ❑U $ []U ❑ $ $ 6/c~ h
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: ~ 3 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL P H T R UNDWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
D/t~
0 -/Lz/~i~//O
B- S
B- g f6: S D/bL 7
B- Oh L 7
6-'j' ~ 0/l.li ~ G'- 3a 3/.65 ,30 ~ 35 "/S~►i~S~g?/~f
B-
~[~l PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
NUMBER JAISWbS AFTERSWELLING INTERVAL-MIN. p PERIOD 2 PERIOD 3 PER INCH
P. J
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 plat plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
t r I I
,
I
f._
oP I sb
I
~ep
I
-eR J. Pa
o Ds
C
64,
rol
I
+ ~ ~ ; i i i I + + I I ! I ~ I ~ _I +
t
I ~ ~ 1 I i I r + 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 prin _ TESTS WERE COMPLETED ON:
r o
1-7 ~(1 r 6 _5 ADDRES CERTIFICATION NUMBER: PHONE NUMBER (optional):
Cwt c .V00 4 iPe /,t U -9- N'46
CST S A UR :
CXd
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHRSBD-6395 (R. 10/83) - OVER -