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HomeMy WebLinkAbout040-1196-60-000 ICI p °y3 03 I N G W a) A C w' O . O ~ I N C 'O N E~ ~ I y c a am n O N_ O E: E w o U O L m C LL h N O a) O E CLT z rn o Z {L C LL C O N t N a w a =y= ' I V f0 M M "t C z N H D) W E E z o 0 v £ o z v 00~ ~ai m m (L am N v i- cn c I o o z d c c n - z O o o N H (D O1 a) z c E c E '2 O 2 rn 9) M O N_ O O N_ CL 0 co (1) o 7 7 a) N N C N C L n • d C ~ n a L L, O L) co ~ C C U O Q O N Q O Q z m z z z o N a) _ i 10, t6 p a) _ Q 10 w N CL Y C ~Vl Q' to GI 0) a) a f0 y N N L O o o o a ° o Q a a a) ° w m m m _E N m y E a ~v =333 o3~3 ~5 Z CL CL CL d J O 7 O N M O N V M M N !A J U j rn } 2 rn a) 0) m Z Cl) J N a 0 O O O O N N w N 11~~ ~O C Co O E N N C M N co C O O m O (D 5~ O CO m N C3) O 'p N 0) (D 0 to U) h c a c ° V C4 9 ` O a) O 'O E N CD M Q a a) c CD ° c r aUi -e c OO a"i c c d °o °o °o L O CO 3 p U) M N N y E r- N N N O O O O C co c N N C 0 -'r co Sir co ~ CO O _ U Z O in - Z d O co a a) 'a C) pOj O U • i>~ 2 O N M U N O E y o o H U N -r co 0 - h- z cA In[ z I V ~ # a w l0 i L L rA a CL L: L: 73 IL (L ` at; 4w E O E c c 3 L o ; m o ; m o t A U a 2 0 m 0 0 U) 0 S ySTE~ ic, Std //O Sip l- • z 3 z y 11 q 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS GuvoY L''~ /f vD-~o.,~ w~ S S yon ~ SUBDIVISION / CSM#~ C77 LOT SECTION. y T N-R W, Town of Zg • 1. g°l 0 ST. CROIX CO TY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. or . a - 13o TI?~4.- c~ o , EA)e, fig 141to it- Tolo of-/c~T,P~'c T,P~1~s Lo2~`/t-7P /3 o X - /00-0 BENCHMARK• ALTERNATE BM: SEPTIC TANK / ER / UUMON 10 o G. Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size ~ Gallons Float separation /cycle: Alarm Location 4 3 rt(~PAJ GEES - :SOIL ABSORPTION SYSTEM ~o 3 Width: Jr Length (vU 6,2 - Width: of trenches &i6s7- z- o7- G.;~F = ieV oelc ; /OQ Distance & Direction to nearest prop. line: Setback from: well:~ZOd House Other ELEVATIONS 7 Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off S~ Header/Manifold Bottom of system Existing Grade Final grade ~J,4A/ SST Z ~ ~z y i yf 3 DATE OF INSTALLATION: ?D PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 2 ~ 3k ~I S W 1 N 6o `J e H q rJ y1 LU ~ ~ ~ tJ ~ Q c h ~ ~ ,2 kz ry . 4 Isi o I ?o ~ a V h ~ 0 ~ _ w h ~ sj- ,J o NO 'Pey to \ Q 'YJ CS W mz~ v 0 0 N S2 ~j X81 m cc X: LA L, 41 L Uti~y L~ • ,PD EDGE i. - • S yST~.~ sfi.4iijv s z 3? z y I .1 1 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS /yv0-ro.,~ ~v~ S S yon SUBDIVISION / CSM# h/,/rA CT ' LOT SECTION. y T 2y N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. .SEI~t,~rfT ~ ~ III REA)e /f 1441V If' /'OA' S& p 11-C' 7111-,)&- 100,770-A-1 ~G Cf tl- ~ BENCHMARK : /00'0 ALTERNATE BM: SEPTIC TANK / ER / ZMATION Gt>iES~.e /oaa G . Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer ModeI / Size Float seperation ~ ,4- Gallons/cycle: f~ Alarm Location "i C G, Es - -:SOIL ABSORPTION SYSTEM Width: 5 Length GU ~OZ Number of trenches 3 w~sT oT G.:~~ _ APO iP~ty Distance & Direction to nearest prop. line: /0 Setback from: well: zod House Other ,u~~~ ~x ►'s r~N, ~lr~j ~o~,P S T, 'C M ELEVATIONS Building Sewer ST Inlet: ST outlet r PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade P40 ~I DATE OF INSTALLATION: f~pT 2-? ^2 1/ / ~Fy 3 PLUMBER ON JOB: 24L19 A,0/ 'C'4 7 LICENSE NUMBER: INSPECTOR: 3/93: j t p0 a 2 kI. 2 Ilk J h a ~ ` ~ M l \ \ Zl~ 41 1311 )z ~ I y,ra~ h '(1 W Q 41 9 2 4 ro tm- Z34 4u 5 S2 M86 052 cc H LAJ -j IQ -V t _7 g CL ` w o Wisconsin DeparUme it of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Hurnan Relations Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must W ckide, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL P n dimensioned, north arrow, and location and distance to nearest road. J APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEVf D DATE PROP RTY OWNER: PROPERTY LOCATION KO/3&j T GOVT. LOT e, V 1/4 AA' 1/4,S Y T Z1 N,R If E (ao PROPERTY OWNERS MAILING ADDRESS LOT al BLOCK i SU D. NAME OR CSM e -5,7 9 L "'o G.,✓ . ///&j6 lPiDGE c tun T CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [ffOWN NEAREST V19 so ,o GU/ S S yo G (7%4-) 3eG - Y/ f3 0,V I le Wy [ 1 New Construction use [ Residential Number of bedrooms 3 Addition to ebsting buiWV j4Replacement [ ) Public or oommerdaf describe D Code derived d* Now y~O gpd Recommended design loading rate Lv -I bed, gpolft2 - -5 trench, WW Absorption area retired 4- bed, It2 trench, ft2 Maximum design loading rate NP bed, gpd/112 • 5 trench, gpr1M2 Recommended infiltration surface elevation(s) lac P 6-. 3 _R (as referred b site plan benchmark) Additional design / side considerations ~.r~c-~~hfs o.~ t y w , D,2y o X J~ 'S T i R U T10,J Parent material 7;1 DN4M14 /04,'-l - 004.1,f6 Flood plain elevation,IWicable -V f ft S - Suitable for SySI1em 0 PRESSURE AT.GRADE SYSTEM IN MOLOW TANK U - Unsuitable W system ErS ❑ U ❑ U L7 J ❑ U ❑ S ❑ S [01 S QIY' SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Moon Texture Structure Consislenos Mu nifty Roots GPDfitz in. Munsell Qu. Sz. Cora. Color Gr. Sz. Sh. Bed lends l D-/ Z /60 y/ 1,9,1,•1 2-f. s6K 1j"&rF - S S 13, log 51 ;V- Ground 6 -3/ /~~/e 3 ~i de n+~fe S I f S elevh C /0 G 5 , 3. P die' tr+ limiting Remarks: ~iPtsf Of ,`y, SdiT~.~/F fz~/~ ~ldU,yQ Sr-S S Boring # S/ .2,f, 6-J,,r ntiivf.~° S 2,F , 5- 13 . G 0-1'y /6 ,P y3 / s6.~ ~'ie ~s r- y , s 13 Ground elev. w~ r~ i o y G~3 GG~y CO.~ s ov ES . : S /D lie y A 6, Depth to limitiC' 10 s D, f, 'Y►1 /rf/~ a ns s i '%e 1 5factor0 ~f,• s ,v~ Nr° Remarks: OF ~v 2..__ S~! r.~~F . ov L y . Flo U•vp _`S~ST. _ s• S . " TName:-Please Print ~ Phone: '~ot3E~ I ~t3~ t'C[~►T 713'' 3R6 -oo/8S ress: (05-57 p ' L ~'D ff v1~s0 a Gv/. s Ya G y'- /F - f 3 csT.~-I IT z Signature: Date: CST Number: ZE:Sl'&-A) LCADI-2,6- RA-tE- eyp /f4 gal ~ ~ p 1993 - CC~iX W TOW rjce /'9 G i~ SOII DESCRIPTION REPORT ~?a PROPEti71f OWWR PARM IA R /0 ~ !~r- I'Pa(r6~- # Horizon Depth Dominant Color M0111015 Texture Strudure Cwslslsnoe Bmrdwy Roots GP( In. Tffinch Munsell t]u. Sz Cont.Cobr Gr. Sz. Sh. Bed /1" 7w ~Zr p / Z9429 9/7-:5 Ground &X ~SSi' E G!/ T elev. eC 7-E'.4v 7dnJ z X N S/` tiJ 7 ~s Wo to 4-)(7t&1-e5e ~iile Remarks: Boring # a,~~ /ayR z/ a,~ ~~'c ! /o~M 1 SDK f/l 5 f Np N 2,M1,b/c -0, Fk S /1) F /0 1/9 31~ E3 21-3 lb yX 5hk f2 a , 5 elev. G.9 s R V/6 AVA MA yA 416 /s f 9~ X- s Dq* ID Ong taC.t~r K Remarks: Boring # b-/d, D Yke 41, fA S. ' y;•S sb/c /M f,Q c 5 ~ Y .S S Pft 3 -3 Q ~D Gmurid r elev. 67 YX Y/6 rc Depth ID tads Remarks: Boring # O_~O All Uf2 S 4-N , S (V 2-1,41A /W '3 f 13 Gmund ekw. p iMng Remarks: con 0o•)n10 Acon' " J UND / `N o_ mQ) 0 o~x `C T r v ~ v w -13 d c o f \ ,o o► m n W O ul m 1 ~m rn C 0 tz~ o ant L N~4 Ud (1 0 4+ M ^ u a N Z b y 4 r. AS BUILT SANITARY YSTEM REPO&T....~d G 'Atli TOWNSH SEC...~_ T2 O N, R W DRE$ ST. CROI COI - WISCONSIN .0. :'BDIVISION LOT, LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r` . . a x, 'boa r , M Ii' TANK(S)6 r e) MFGR. CONCRLTE 5TFE1. NO. of rings on cover Depth UF.Y WLLI. i S NO.;pf width length area 60 no. of 1l4e1 Width_ ! length Za 4v ,$'",L area__Ldepth to top of pipe ~;:CR$GATE AREA REQUIRED AREA AS BUILT sciaimer: The inspection of this system by St. Croix County does not imply complete ;ipliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for the !:tem operation. However, if failure 19 noted the County will make every effort to termine cause of failure. ;ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. is 'INSPECT DATED- 7 PLUMBER ON II ~y~ LICENSE NUMBER , Lci LQpart~~f Irlesr • 19.891 PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitary ermit o.: • GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village k Town of: State POW o.: 11 lev.: nsp. M Elev.: Description: X Parcel Tax No.: BM 040-11 - 96-20-000 TANK INFORMATION ELEVATION DATA A9300254 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent irIto ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade I Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss H Forcemai n Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER Model Number: INFORMATION Type O System: 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 xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 4.28.19.891 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: M LHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than IC1 041- F 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 h'd!s r7- ' J~aE7 4, .4GV Y.10C%,S e/ TN,RE(or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # S "7 L_L; vj) L-Ap /9 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER OS'd•," fol. SQrG 3 w i'(-ff toG~' eo v T` Li : 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ LAGE j'• y G vtJ~ L,,v ❑ Public 1( 2Fam. Dwelling-# of bedrooms 3 PARCEL TAX NUMB Ill. BUILDING USE: (If building type is public, check all that apply) O /O - f Ca 7 - 0000 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 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.E1 New 2. ~eplacement 3. ❑ Replacement of 4.0 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 O'3eepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure i 43 ❑ Vault Privy 14 ❑ System-In-Fill '_rj?4EI~;7-5 a-,* C& S' )(60 VI. ABSORPTION SYSTEM INFORMATION: ~y 7 5' 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 (s q. ft.) (Gals/day/sq. ft.) (Min./inch) IN. U LEVATION 700 5?00 Feet O Feet CAPACITY VII. TANK # of Prefab. Site Fiber- Exper. in allons Total Manufacturer's Name Con- Steel Plastic INFORMATION New istin Gallons Tanks oncrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank 160y 7 t:1X LiftPump Tank/Siphon Chamber CePVCR4Fr 4a- Vlll. RESPONSIBILITY STATEMENT 1, 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) MPRSW No.: Business Phone Number: liWeer P 7 C Address Stre State, Zip Cod O J ~ Z;5~~O ~ s IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa itaryPermit Fee (Includes Groundwater Date Issued Issuing Ag t Sign OS ps Approved ❑ Owner Given Initial Surcharge Fee) a Adverse Determination o J X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety A 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 tine of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions tL this permit must be approved by the permit issuing authority. 4. Changes in owrership or plumber requires a Sanitary Permit Transfer/Renewal Form 6399) to be submitted to the county prior to installation. 5. Onsite sewa~te ~-,ystems must be properly maintained. Th,-, tank(s) must be pL!niprd ;)y •3 licensed pumper wheneN er necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your loo al code adr-0n1str3.tor or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. s To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax numher!;s) of where the system is to be installed. 11. 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 line B if permit is for tank rE placement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information rea,iestr.d in #1-7, VII. Tank onforrr'ation. Fill in the capacity or e,,,. ry r!ew and/or cx , `.kv tank, st tire; otal gallons. r~~n uer of tanks and manufacturer's name. Indicat6 prefab or site constr tciu and tank rE,rterial. Co~~~~le#:' fcsr all septic .QL~rnpr`siphon and holding tanks f10- LJS system. Check _.erirnsri a! tlnproral only i1 tanks received experin; ;=;:ai product approval from Dii-'F;rt. VIII Responsibility statement. Installing plur°,?;-,- is to fill in nan!e, license nu.mbe~ !,Yitn approprwte prefix (e.g. MP, etc.), address and phone number. Pl;;ngber mu,>t sign szpp'ic„tor form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not sr. Eller than 8% x 11 must be s(a omitted to the county. The plans no;st include t,w- follctwlr,g A) plot 1. craw-, to sc~oi ; tfcomple* loc3tian of holding tank(s), Sept!^ tark's•) if -(-Jher trei,tment tanks; :worc,, well~._ water service; stream-; and lakes, purllp sr tanki; distribution bo*t, L:=,o,i,t!: r! :.,=tom : r~•': ,;pr,e: t system F ari_>aS' and the ioCati 'rl of 4i,` q-nip (1) complete specifications for pw ;uu and controls; dose elevat on u,tle,ences; friction ioss; pump performance curve; pump model and pump manufacturer; D) cr~_su section of tre 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 s'.lrcharges are used for roon!tcm j groo }dwator w :unu ; water con`an--dr.atlon irvestir,w?ons and estah-lishmen! of standards. SBD-6398 (R.11/88) 1 ~ U,up ~ L.v 0 c Izz 09 -t h s 6)~ti,~'~' Z w\ * a i l r ' v 151 ~ I O In i 70 70 ti ~ rn fi c 1 13N z d W w - ~ O ~ ~ tTj c a a (~j G o Z Ri - w ZOO I gRayL N"u y M ~ ;t N, Z~ d y 4 Approved Veat Cap bove _ Minimum 120.P Final Grade ~NiSJYEL~ / Ti0E oer A _ 4' Cost Iron 'Above Pipe Vent -Pipe' u Final Grade Synihelic Covering min. 2' Aggregate Over Pipe Oistrlbuilon - Tee pipe 0 0 0 0 0 (o Aggregate 0 Fwfbroled Pipe Below Beneath Pipe o -Coapline Terminating At Bottom Of S.yslew sys7~"M Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12" Above GAT Final Grade Cost Iron 36 'Above Pipe -Vent 4ipe' 'To Final Grade ' Synthetic Covering Min. 2" Aggregate Over Pipe Oistributle. - Tee pipe - 0 0 0 0 0 a Aggregate o Perforated Pipe Below Beneath Pipe o -Coupling Terminating At s ysr~M Bottom Of S.ystom Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12" Above Final Grade TiPE~U`~- 97 Sv , _ 4" Cost Iron 3 *Above Pipe Vent Plow -to Final Grade Synthetic Covering min. " ODistribution - Toe Pipe Aggregate 0 Perfor ated Pipe Below Beneath Plpe 0 Coupling Terminating At S~SrEM Bottom Of System ~ -3 AS BUILT SANITARY YSTEM REPOEZ..,~ ' TOWNSH SEC. T ~O N~ R W o. ADDRESS',- ST. CROI CO WISCO 1N ftiDIVISIOH LOT-JELOT SIZE PLAN VIEW -Distances b dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM t M ~ I /b 0 C, lm~ Al i . ~.~y rte. »Q, TANK(;? L6 v ,e,J',. MFGR. G!/.,e.~t,c, ~.~z.~~ CONCRETE STL.EL._.._._...._.__....__...~.------._~.~..._~ NO..of rings on cover Depth , URY WELL S NO, pf width length area of 1#.eji,~ ~ Width length__~ area, , depth to top of pipe ' A"A REQUIRED/d AREA AS BUILT sciaimer: The inspection of this system by St. Croix Country does not imply complete !,apliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no ltabtllty for <.tam operation. However, if failure is noted the County will make every effort to termine cause of failure. "•%ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. ~ --INSPECT6? Dl,= PLUMBER ON J0 _ LICENSE NUMBER, Y !Y I..._....._.... 10, ST. CROIX COUNTY ZONING.OFFICE CERTIFICATION STATEMENT A FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the J'~A)cr residence located at: S~Lt/ 1/4, /vim 1/4, Sec.T2-f_N, R 11 W, Town of Y Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced /Au G-(jS'T- vT 7 3 2 Did flow back occur from absorption system? Yes ' No (if no, skip next line) Approximate volume or length of time: gallons' minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer ( if known) : w DES CO u(~7~~ moo- Age of Tank (if known): R0 /3GP- 7- 2,t 4,13 R t'C- 47- (Signature) (Name) Please Print J,--g am-, 1-t4,,of5 33o7 (Title) (License Number) (Date) Form 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). MP/MPRS 3 3 Name T 7-Signature 5/88 u7~+~7icvi:wr ..+MnwRar.+~-•m*...-.,y, ,...,,.,i W'ww~ D°ps"nRelatioe"c°~I" nsd SOIL AND SITE EVALUATION REPORT Pape of Laborand Hum 3 Division of Safsq & euikings in accord with ILHR 83.05, Wis. Adm. Code COUNTY G1691X Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must indwle, but not limited to vertical and horizontal reference point (8M), 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 PRO~rFRTY OWNER: PROPERTY LOCATION -,C013E~e T GOVT. LOT Sub 114 N~_ 1/4,S X T 24"' ,N,R If E (ao PROPERTY OWNER .S MAILING ADDRESS LOT = BLOCK i SU . NAME OR CSM i S7 L ",p L.✓ /Q f ~ti R1;0611=_ coo iW 7. CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE UOWN N EST yy 14,v uD so Gvls S y0 G (71j-) Ava - y/f3 T/Po ZeWpD L 1 New Construction Use ( Residential Number of bedrooms 3 (J Addition to existing building 1'Ont I I Public or conmeraal desaibe Code derived dally flow yJ`D gpd Recamiended design loading rate N P bed, gpdO - S trench, WW Absorption area required VA bed, ft2 trench, h2 Maximum design loading rate tVP bed, gpW • 5 trench, WW Reoommertded infiltration surface elevation(s) S-a.L Pit . 3 R (as refefred to site pan bertdtmarIQ Additional design/ site ao Wderations 7l ~r uG/,~S o v y w , DQy a X ~t'S TR r' Q u 'r~o Parent materiel S=CS Y D,v,fM~A- arlw,fSlk FloodpFairtelevation,i(applicable Al It S - Suitable for system D PRESSURE AT•CRADE SYSTM IN HOLIM TANK U - Unsuitable for system S ❑ U ❑ U NS ❑ U ❑ S ❑ S ❑ S O lk- SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color MOWN Texture Structure Cmsistenoe amrd3y Roots GPI in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mnCh p-fit !a iP z 2f. Sbk 4,v,vfR_ S 3 57 U 4 1 v % -/6 /o ,e 311 Ground 131- Mau it C is ye G 5 , 3 . P S./ ,6,~ fe - s Depth a limiting 1 Remarks: 4iej•¢ of ,a, sdirlexe- 'ea /-y fd/' ~10U~0 s•-S• s Boring # ~oy~ 3~1-- S~ 1 56,E vf~ S 2 S ? . fib ~'S /vF . y S Z Z31 1-1- /6 ,C' y3 s/ ~f s~,e 4m 4-m e 57 i S = Ground dev. w,Y~_ y G/3 y • s d~ ES yD/',e y G' R Sam/ 1, f slot ~►•~,FI• 0.57 . y '5 D"ID -5-Y bCtDr N /o y~ ~~y s/ , 9~ ~f,• Q Jr 4/P S• S S . Remarks: /32 Stoi'7` ~I'f3/~ o v 4y h=od /Io v vp sy f r. CST None-Please Print PO ?a-E1? T' U P G e" C (,c T Phone: 7/,,5- 3 d - 6/ 8 S res:: 65-5 O' NEIL RP h`VPNO a SycvG y'- NSO- y'3 CSTM yyPi Spnature: Date: CST Numbw: i LUh D1 -z-& P AT E _ GPV /f RE~uI~t(~ - I/Jsf~I~ 3 YIC'E~ES ,hGG~ 5 x (oO SOIL DESCRIPTION REPORT pap ?d PROPEATr OWNER PAMLQ= LD 1~ %6Li /~G~~ poo Dominant Color Mottles Texture uc Sh. Coralsove Boun by Roots BGedPD Bop # Horizon in. Munsell Ou. Sz. Cont. Color Two 3 ~ /o R 2-I /,-f sb~ ~6f ti ~ 4/~ `l/ ' `1 t r D -f.-/ ~~i s/7-75 Grand O~ ~D .y X G SSi' E 7 elev. ~,t' Si` 7 Dept, 1D ~F(rGe;e,-17-V diD 1s Ae .vo r 4e,v svl747 tae Go v sys -y Remarks: Boring # ley 1/l ow&4,v,-c 1w fjl S 1o N N z 1~ /0 V12 3 ,b/c n.►,, f~ S 1 v F I S -3 o y, 5h,& ,,,,,,1f'~e S s, gA- S. elev. C -gyp Y2 Y ;ll,A ifv-416 -F 4-M X- Depth to 17 Remarks: Boring # D ~►r+fA S. ' y`=:,•S Now 057 14/11 73 lo u _Yle 3Z3 Grand ~D s y s X vfR -f ~P elev. YX Depth t Remarks: Boring # p ~~p b R s~ Z,~, Sb~C n+► Uf 2 . 5 ~s 3f . s S/ I'm ~K > a-2~ Z 9,P,~,ciry GUM e Y16 Depth b kmifing Remarks: con awwwo ncinn% UwD / `N 0 c ach • o m Q1 O` ~ to 3 wm o ~ o ~ I 70 m t m Ei Z Z ~ d W a ~ ~m rn NJ 11 o c tN L ~O b y d a S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /Q&XV (,~v ZAA.%E L ` C A;'?6-;Q ADDRESS? FIRE NUMBER CITY/STATE A&P SO-cJ r S_ f 4+ ZIP cS 4~G~/ PROPERTY LOCATION:'S~) 1/4,41 1/4, SECTION, T N-R L9 / W TOWN OF_ St. Croix County, SUBDIVISIONS LOT NUMBER /4Q 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/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 must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration te. SIGNED: G(J DATE: __/~I St. Croix cp. Zoning Office 911 4th St. Hudson, WI 54016 I, 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/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 AA&-R7 `L! 44.) 1 Location of,propertys 1/4 _1/4, Section Ta N-R JYW Township /P 0 Y Mailing address ( y G~ Address of site s subdivision name /fi6-4. C-00/P 7 -'Lot no. ~o Other homes on property? yes C/No Previous owner of property Total size of parcel Date parcel-was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes Volume &60and. Page' Number /3-5 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 he pffice of the County Register of Deeds as Document No. it. Ct 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 recorded in the office of County Register of deeds as Document No. Signature of appl ant applic t ( 1 Date of ignature Dat of Signature i DOCUMENT No. 'STATE BAR OF WISCONSIN FORM 1-198a THIS aPwca Rcsenvro FOR RECORDING DATA ' WARRANTY DECD 315Z3(;6 VOL 660 MU 13'J REGISTERS OFRCE This Deed, made between ST. CROix CO., wa Kenne.th..R_...Jo s.on.-and..Do.lores...J.ohnson,..-husband Recd. for Record fhh Is .and- wife.:aw***F-x.nt_.t.ehants-_-----.---- day of March A.Q 83 , Grantor, 12:45 P and.Rober:._"1ei..._Hell.xnge_x._.and.-J-ane--.I.-•---~e.lingex..,--- at k» husband-.and..-wi..fe---as...jo at_--r-elaan.t~s--------------------------- arFee Grantee Witnesseth, That the said Grantor, for a valuable consideration-Q.f. One ..Do.ll_ar_-aad._Qthez...Go.od_"and.-val.uabl.e._C.gns Weration: - ♦ . : conveys to Grantee the following described real estate in ...S1-...-.Cro_lX......... I RETURN TC County, State of Wisconsin: Tax Parcel No- Lot 18, High Ridge Court First Addition to the Town of Troy, St. Croix County, Wisconsin. ~I ANSFF2 $ AA,Z.Q FOR is This homestead property. (ig) tw M Together with all and singular the hereditaments and appurtenances thereuito belonging; And....Kenneth-_R__..and.-Dolores.-Johnson.-------------- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any, and will warrant and defend the saine. March 83 Dated this ...1st day of -------------.r..-.-.., 19......... - (SEAL) . - (SEAL) i f Kennet R. Johnson - (SEAL):'-- •w1GEAL) Dolores ' hnson a + AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. County. authenticated this ........day of--------------------- 19 Personally came before me this I-St......... day of ..............March----------"----, 19_&3_. the above named Kenne.th--R----Johrns oa_-and--.--------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not- - ~a authorized by 706.06, Wis. Stats.) O r`'Y n to be the persons who executed the 2 fore„ strument UdI7.,,, owle dge the THIS INSTRUMENT WAS DRAFTED BY K.J. RUSSELI. E. BERG BERMUELL i Attorney at Law - River Falis; W-1: 5442 'r? vot+zistie'.e.rf'< County, wig. ~+ssion is permanent.(If not, state expiration (Signatures may be authenticated or acknowledged. F ~ ar not necessary.) OF S ~s -J_rlne._..--2;3.-_..--. ) •Names of persons signing in any capacity should he typed or printed below their signat-~r- mss -7 ~ ~ L7 L I /,So J 03 I 5 1l(5 I .On: W COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST. CROIX COUNTY GOVERNMENT REPORT NO.: 47541/01 PAGE i CENTER REPORT DATE: 8/25/93 1101 CARMICHAEL ROAD DATE RECEIVED. 8/24/93 HUDSON, WI 54016 ATTN. THOMAS C. NELSON OWNER: Janet Betlinaer LOCATION. 579 Lundy Ln. Hudson, W1 COLLECTOR: Jim Thompson DATE COLLECTED6-23-93 TIME COLLECTED2234pm SOURCE OF SAMPLE'+ kitchen faucet I DATE ANALYZED.$-24-93 TIME ANALYZED:2S00 COLIFORM,MFCC4 0 /100 mi. INTERPRETATION. Bacteriologically SAFE NITRATE-N. 4 ppm Above 10 ppm exceeds the recommended PubLir Drinking Water Standard. CoLiform Bacteria/100 mL Nitrate-Nitrogen, mg/L I LAB TECHNICIANS Pam Gane OF,NOEVENOFNl, WI Approved Lab No. 19 V > Means "LESS THAN" Detectable Level Approved by. d 0 PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 - (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. ❑ Water (VOC's) $185.00 ❑ Septic X $25.00 ❑ Water (Nitrate & Bacteria) __jK$35.00 (Visual inspection) Se_A-» ' G.~YK~Tt'► trill Nfi F~~ty 9uested by: owner: -F'fx.►'3~~ I i Re Address: 1 "4 Address: np ! . City & State ~,t'.•~~ r ~ , Lc city & St. tt~ sa,~ Lp Zip Code:s f. h Zip Code:'5L401b Telephone N4• Telephone N4: ( ) 3`6~ -BZ-'~b Property address (Fire NO & Street) : 5-7C1 L-Lj- n-~'-'` Location: PIS Si✓ Sec.4T 2S N, R__W, own of-,Tv-c> y St. Croix Co., WI. Tax ID NO Parcel ID NO House color:~rcnxm-N Realty firm: Ec~ir Lock Box Combo: xWater sample tap location: LVJ c~'j , r,' -f , 'T, ( r_' f -i . j t f l--c TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Is the dwelling currently occupied? ,k Yes 0 No If vacant, date last occupied: Septic system installed by: 01 Ems Year: _I Septic tank last serviced by:7Rl--C~0(-W7V SEpTIG Date: q Previous Owner's Name(s) : Sahnse+'~ i~~ Have any of the following been observed? ❑Y 4N Slow drainage from house. f OY N Sewage Back-up into dwelling. ❑YN Sewage discharge to ground surface, road ditch or body of water. ❑Y Slow drainage from the dwelling. RE~E~,O ❑YN Foul odors. 93 A~r1g19 Other comments relative to system operation: w SS I certify that the above information is complete a q, e best of my-knowledge. DATE: OWNERS SIGNATURE: 4/93 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN TO BE COMPLETED BY INSPTION AGENCY System design &/or permit on file? Yes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: 2VrFaf ow grd 0At-Grd OMound Approx. size X~' _ity []Dose OPressurized ~Ft.2 WBed []Trench []Dry Well []Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES 00ther OUnknown Septic tank Setbacks: OHouse OWell OProp. line-460ther e ank Setbacks: []House []Well OProp. line 00ther []Locking cover []Warning label []Pump/Floats OAlarm []Elec. wiring Soil Absorption System Setbacks: OHouse []Well ? OProp. line Other ❑Ponding: ODischarge: General comments: Ntt INSPECTORS SKETCH OF SYSTEM LOCATION d 3 c o Q Inspecto Title • _ AS BUILT SANITARY YSTEM REPOP__._ " TOWNSH SEC. T -:?O N, R W •0. DRES ST. CROI CO WYSCO 'iiDxVISION LOT LOT SIZE PLAN VIEW r -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Y -M0 ; TANKO;) b a N) MFGR. CONCRETE t" _ STL EL _ NO. of rings on cover Depth DRY WELL ► S NQ. ;Of width length area '0Q, no. of a width+ I i length ~ area depth to.top of. pipe CD~ f N AM, REQUIRED AREA' AS BUILT scha.imer: The inspection of this system by St. Croix County does not imply complete npliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for .item operation. However, If failure is noted the County will nuike every effort to termine cause of failure. _•;ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. 1 --INSPECT AA J .03 DATED --~L•~~-------7 PLUMBER ON JOR-_ - - - LICENSE NUMBER____'22 Gt~_w f' ST. CROIX COUNTY WISCONSIN PLANNING & DEVELOPMENT PLANNING SOLID WASTE REAL PROPERTY ZONING 715-386-4674 715-386-4623 715-386-4677 715-386-4680 August 23, 1993 Ms. Kathy Smith 700 2nd St Hudson, WI 54016 Dear Ms. Smith: An inspection of the septic system serving the Janet Bellinger home located at 579 Lundy Ln., Hudson was conducted on August 23, 1993. This inspection was based upon a surface inspection of said system and did not involve any excavating or chemical analysis. Accordingly there may be hidden defects in the system not discoverable by this inspection. It is very difficult to estimate the useful life remaining in any septic system. Their failure is a progressive decrease in the systems ability to allow sewage effluent to seep away from it. This results in the disposal of less and less effluent until a point is reached where the system fails completely. At the time of inspection, this system appeared to be functioning, but not at full capacity. I noted that there was sewage effluent ponded within the septic system, which indicates that the system is fairly far along in the progression of failure. I cannot predict however, how long this system will continue to properly dispose of sewage effluent nor how soon the system will reach complete failure. As a result, I cannot guarantee or warrant that this system will continue to function properly in the future. In an effort to prolong the system's life, I recommend that steps be taken to minimize the wastewater flow from the house which enters the system. For example, repair any leaking water fixtures and/or replace them with water conserving fixtures, reduce time spent in the shower, wash clothes and dishes only when there is a full load, use a washing machine with a suds saver feature, etc. I would also recommend that you have the septic tank pumped at a minimum of once every three years. Should have any questions or concerns that I can clarify, can be ed at this office between 8:00 am.- 5:00 pm. , Monday - Friday. Since ly, es K. Thompson Assistant Zoning Administrator ST. CROIX COUNTY GOVERNMENT CENTER • 1 101 CARMICHAEL ROAD • HUDSON, WI 54016 AS BUILT SANITARY SYSTEM REPORT iOWNSH SEC. T eN, R W ,0. L+RES ST. CROI CO - SCO7NSIN 817I VI S I ON LOT _LOT SIZE PLAN VIEW 'Distances b dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Y Si r !t e 7 1 CONCRETE 1-' bTF.EL TANK (8,)J& a e) WGR. [ N4. o tings on cover Depth DRY WELI.~ zmas No. of uldth length area so., of ],,i.~ e"* Width. length_~ area_ - dep~~tc~p of pi e P RAUA RL UIRED AREA AS BUILT sclsimer: The inspection of this system by St. Croix County does not imply complott, 1pl.isnce with State Administrative Codes. There are other areas th<:it it: Ls not pos!.ihle inspect at this point of construction. St. Croix County assi,imes no liability for tam operation. However, if failure is noted the County will nuike every effort to tertaine cause of failure. SASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. --INSPE CT (I 0? DATA. -7_ PLUMBER ON J01; LICENSE NUMBER C z • REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.itany Permit _ State S Q pt~ c t i Jownz hip St. Cno.ix County NAME 'an S ct.c, Location C ae SEPTIC TANK I Size ga.L.2on4. Numb en ob Compantment. i ViAtance Fnom: Wett 6t. 12$ on greaten Atope_,it BuitdingWettandb ~ • H~.ghwaten " it. DISPOSAL SYSTEM Viztance FAom: Wet a fit. 12% on greaten stop~.it• Bu.itd.ing 6t. Wettands Ft. H.ighwaten FIELD DIMENSIONS: Width o 6' thench it. Depth o6 na ck b etow ti.te-)-~--.in Length of each tine it. Depth o6 rock oven t.ite=n• Numbeh, of tines Depth of t.ite below grade Z-~ .in. Totat .length o6 tines it. Stope o6 tneneh ~ .in pe,% 100 it. i Di4tance between Una ~ it. Depth to bedrock ~t• Totat ab,6onbt.ion area Ll, q 6t2 Depth to gnoundwaten Requ.i&ed area it2 Type of Coven: ap on Straw PIT DIMENSIONS: Number o6 p.itz Gnavet around p-i.t.b yea no Out6 ide d.iamete,% 5 Depth below inlet St. 2 17 Totat abaonbt.ion a e it y2 Area nequkxzd ~t2 rn INSPECTED BY~,~...`'~' TITLE' A . , DATE Z, 191. APPROVED 191_. REJECTED I DATE r, i t , EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES s DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH • P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: i5E-'/4, C'/4, Section V, TCXN, R L E (or)~f wnship or Municipality ~~6Y Lot No. 1 Block No. County c division Name Owner's Name: j an ` Mailing Address: kw e!'A ,5-y6.!9 ~ TYPE OF OCCUPANCY: Residence S_ No. of Bedrooms 33 Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS /D/~4172 PERCOLATION TESTS c~/E ®(»Q ~j~ SOIL MAP SHEET SOIL TYPE AM1')') 4 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN t'. BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P _W116S A)VIVE XIEQo~,e P ( * 1( 1l I ->,_X~"CaD A,00 p~ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B 4F r, 4 q8 . ,r R S t K L. 4 e 9,Q -A CIS' 8rr PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable r as. Indicate number of square feet of absorption area needed for building type and occupancy. / Indicate scale or distances. Give horizontal and vertical reference p . Indicate slope. Co 6-0- `r tj 1j 6 8 4 t N 'r A~A A~ l l ' r Ined, hereby certify that the soil tests reported on this form were made by me in accord with the procedures specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct my knowledge and belief. l l i Ef 0, 0 Certification No. L~J C~`d GC.5 if known J ~ kAL AUTHORITY CST Signature PLB67 State and County State Permit Permit Application County Pe t for Private Domestic Sewage Systems County -~'~1 *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OW ai)_ n Pk.0-5. 6, /_),A),S-7W OC 710,1~/ _kj~t_Awl NER OF PROPERTY Mailin Address: J B. LOCATI o N& Section , Taff N, R E (or) Lotpp# City Subdivision Name, nearest road, lake or landmark Blk# ice( IC/O6 tA„Village Township QY. C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms 1!3 No. of Persons _ D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder ;GYES NO # of Bathrooms-/- Automatic Washer -sw. YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation >e_ Addition _ Replacement _ Prefab Concrete *Poured in. Place Steel Other (specify) F. EFF T DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total ea sq. ft. New Addition Replacement *Fill System Seepag Trench: No. Lin. Feet Width Depth Til a th No. of Trenches Seepage Bed: Length rWidth % Depth pTile Depth No. of Lines 5 Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land ~J°ytT ! Distance from critical slope-.2 :7 I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certif' d Soil ster, NAME C.S l and other information obtained from 1 (owner/builder Plumber's Signature )MPP PRSW# Phone # 7[ - _,2 '737- Plumber's Address_ oQgleQ ~ 4g_ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in. accord with H62.20, including well). LC>T C_, C I~ 4k ~j i oM~ 7S Sec © P Rov&:E) 2, D Do Not Write in Space Below FOR DEPARTMENT USSE/~ONLY nJI Date of Application _ --Fees Paid: State/-5-100 Countyo( 0Q Date Permit Issued/Rd (datwel' 1,6 • _Issuing Agent Name ' Inspection Yes No Valid# Date Recd 1. county (whXecopy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1 /76