HomeMy WebLinkAbout040-1219-20-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER_ ~s
ADDRESS f~-
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SUBDIVISION / CSM#LOT # Z
SECTION T_??N-R__&W, Town of QZ
l03
ig. 2g . 101-10
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
vt{
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ke
33
Be _ ►
~~2fC Ya ✓ 7 ,
A/d well
v ( INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
71
ALTERNATE BM:. "r
SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION
Manufacturer: l ZL,6 Liquid Capacity:
/
Setback from: Well House -7 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: 4L Length Q Number of trenches
Distance & Direction to nearest prop. liner /1/D2iC
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet , Z
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade JY,} Final grade
DATE OF INSTALLATION: S` 3
PLUMBER ON JOB:
LICENSE NUMBER: 31 ~'9
INSPECTOR:
3/93:7't
DILHR SANITARY PERMIT APPLICATION
In accord with Ill 83.05, Wis. Adm. Code COUNTY.
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 193 3 (0/
8% x 11 inches in size. 54 Chick 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.
PROP T)Y OW ER PROPERTY LOCATION
C '/4, S Tay, N, R E (or
PROPERTY ER'S MAILIN9 AD RESV_- LOT # BLOCK #
I
CITY T TE ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER
11. TYPE OF UILDING: Check one CITY NEAREST RO
( ) ❑ State Owned VILLAGE : O ,
TAX NUMB ( )
❑ Public 01 or 2 Fam. Dwellirl of bedrooms - 'PARCEL N W:
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo O!va r
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. [Z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 [21 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
O Z d , Feet Feet
VII. TANK CAPACITY Site
INFORMATION in gallons Total # of Manufacturer's Prefab. Fiber- Exper.
New istin Gallons Tanks Name Concrete Con- Steel glass Plastic All
Tanks Tanks structed
Sell Tank or Holdin Tank
Lift Pump Tall hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsits se ge system shown on the attached plans.
Plu er's Name (Print): Plumber's Signature: (No Stam IQM MPRSW No.: Business Phone Number:
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IX. COUNTY/DEPA TM NT SE ON Y
Y
❑ Disapproved Sanitary Permit Fee (includes Groundwater a e Issued Issuing A nt Si
Approved E-1 Owner Given Initial Surcharge Fee)
Adverse
Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerlyPlb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. ,A sanita.y.,,permit is valid for two (2) years.
2. *dur''sanitary`perCUit 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 to4ristallation.
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 j '
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate thissanitary permit application must include:
I. 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 line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from 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 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; yells; 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.
Y 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'contaminat'ion investigations and establishment of standards.
SBD-6398 (R.11/88)
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L~f5 i~a'~de ¢ertr F~ln~st~q~ • 19, NE, N$111WE ?EVME ~Vif&A County:
Labor and Human Relations INSPECTION REPORT
Safety arrzi Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
. GENERAL INFORMATION
Permit Holder's Name: El City E] Village IR Town of: State Plan ID No.:
-ECISR lev.: Insp. BM Elev.: BM Description: ~s Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9300021 f
I ;I
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic c e-eS ~1G Benchmark /W, V6 /00,0
Dosing
Aeration Bldg. Sewer v°;t'
Holding St/Ht Inlet ~5 quo
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic A 471 NA Dt Bottom
Dosing NA Header / Man. '21 a3 95 - ,~3
Aeration NA Dist. Pipe 7. /
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
/ t.x..r .E%r
Manufacturer Demand r'~r fir, ?je~i 9
Model Number GPM
TDH Lift Friction System TDH Ft
Loss , Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trgnches PIT No. Of Pits Inside Dia. Liquid Depth
a_ l
G O / DIMENSIONS
DIMENSION
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O , CHAMBER Model Number:
System: "A y~ yvo 7 y/ OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length ~ Dia. Length ~j Dia. Spacing G
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over i Depth Over $ ^ xx Depth Of xx Seeded/ Sodded xx Mulched
' ges Topsoil El Yes E] No ❑ Yes ❑ No
I
Bed /Trench Center Bed/TrenchEd
COMMENTS: (Include code discrepancies, persons present, etc.) 'Cl L4
~
LOCATION: ~,8.28.19,NE,NW, LOT 2, RED BRICK
L<,/~.Q amt ~-^o
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4
Plan revision required? Wyes ❑ No e
6
Use other side for additional information.
/ze
SBD-6710(R 05/91) Date. Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION
Ca1,LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY A Ne
STATE SANITARY PERMIT 41
-Attach complete plans (to the county copy only) for the system, on paper not less than G/
8% x 11 inches in size. ❑ Ch1k f r~to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
P ERTY OWNER PROPERTY LOCATION
r '/4,t/G/ S T,;11e,N,R/91 E (or OgE PROPERTY OWNER'S; AIVNG A D~IESS LOT # Z BLOCK #
CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME ORe&WWUIR9M
S 6 e4 r ilte- L-0
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
Z'1' ( ) State Owned ILLAGE : 0 c
❑ Public or 2 Fam. Dwelling-#~ of bedrooms 3 PARCEL Ax NU B _R( S)
III. BUILDING USE: (If building type is public, check all that apply) O yd - 1.2-1 fl
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPPE~/OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. V New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 Reconnection of 5. ❑ 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
5015-4 S1~S" ,.5- , L Feet Feet
VII. TANK CAPACITY Site
fab. Fiber- Expp.
in allons Total of Manufacturer Pre Con
INFORMATION New lExisting Gallons Tanks 's Name oncret - Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank =:F=
0 El
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite s age system shown on the attached plans.
Plu 1r's Name (Print): Plumber's Signature: (No Stam MR/MPRSW No.: Business Phone Number:
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umber's Address (Street, City, t , Zip ode):
13
. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Si nature ( Stam
AA pproved ❑ Owner Given Initial Surcharge Fee) Q
Adverse Determination U/~
X~'~CONDII)TINS OF APPROVAL/REASONS FOR DISAPPROVAL:
J UJ ell' lh? a 1~i%c .N~ u~ l.'S3
eo~
4~0~0_,7 d _2~,6
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 installetion.,
5. Onsite sewage systems must be properly maintald . The septic tank(s) must be pumped by oflicensed'
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, 608-266-31315.
To be complete and accurate this sensaty 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 _ipstatled. ,
II. Type of building being serVe'd. 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 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.
~i
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The '
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems;- replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by-10 Ounty; E) soil -test data on a`IT~ form; and F) sill"sizing information.,.
y GAdijWWATk SWCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
Thermonies collected through%these surcharges are used for monitoring groundwater j'grouno
wafer contamination investigations ana establishment of standards: ,
SBD-6398 (R.11/88)
r
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), 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 40
0-'~---f~
Location of pr perty //F- 1/4 A1/4, Section , TZ-2 N-R19 W
Township
Mailing address ~►J
Address of site
Subdivision name Lot no.
other homes on property? yes 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 YNo
9 and Page Number /6 as recorded with the Register
Volum,9~zz~
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 Ap}~ the ofpce of the County Register of
Deeds as Document No. YOL"? V , 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
recd e of ice of County~~R,gi er. of deeds as. Document
No. -
Signatu o applicant Co-applicant
3
Date of Signature Date of Signature
DOCUMENT NO. THIS SPACE RESERVED FOR RECOR04MG DATA
-WARRANTY DEED
STATE BAR OF WISCONSIN FORM 2 - 1982
484795 ;.132 ~
REGISTER'S OFFICE
David R. Knighton _ ST CROIX CO., VVI
o Wd for Record
_ JUN 171992
conveys and warrants to 3:20 P. M
Delta Construction Company, a M Corporation 0
Register of Deeds
RETURN TO
the following described real estate in St. Croix County,
State of Wisconsin:
Tax Parcel No:
Lot No. 2, Clearview Addition
Subject to Declaration Establishing Protective Covenants and other easements
of record.
CR ~kNt N
This is not homestead property.
(is) (is not)
Exception to warranties:
Date is 1st day of June 1 g 92
(SEAL) (SEAL)
David R. Knighton
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGEMENT
Minnesota
Signature(s) STATE OF l
ss.
Hennepin County.
Personally came before me this 1st day of
authenticated this day of , 19 June , 19 92 the above named
David R. Knighton
I
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person who executed the
authorized by; 706.06, Wis. Stats.) 7~egoin strumenl a ack ledge the same.
THIS INSTRUMENT WAS DRAFTED BY
_Mti David J. Butler Attorne : David J. Bu ler.
e ve So, Suite 526,
Richfield, M 55423 Notary Public Hennepin CountyAft M
(Signatures may be authenticated or acknowledged. Both MY Com ' expiration
are not necessary.) date: 1 ) iau "AN
Names of persona signing in any capaciy sh 6 be typed or printed below their s gnat- ~yyE slaty ~N
w
WARRANTY DEED STATE BAR OF WISCONSIN . NnSCONStN REALTORS* ASSOCIATION
FORM No. 2 - 1982 4801 Hayes Road, Madison, Wisconsin 53704
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS FIRE NUMBER
CITY/STATE ZIP
PROPERTY LOCATION:1/4,/V~1/4, SECTION T N-R-d-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/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. Crox Co. ~nin Officer within
30 days of the three year expiration ate.
SIGNED: /
S
DATE:
St. Croix co. Zoning office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND, PERCOLATION TESTS (115) MADISO
N WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNS HIP/M1J11TCtP*bf+-Y: LOT NO.:BLK. NO.: SUBDIVISION NAME:
F '/a Nw'/a 51 /Tw N/Ri9 E to ~,~v, 2 v i ew
COUNTY: f3WfdER~S BUYER'S NAME: MAILING ADDRESS:
'oz Y'v xg
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
2Residence 3 IYJNew ❑Replace L
,i e
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GRRO]U,NND-PRESSURE: SYSTEcM-IN-FI LHOLDING TANK: RECC~OMMENDED SYSTEM: (optional)
El U OS [1U EJS ~U E] J 29 El S ~ Co A,Ve l AI - 'I ZSE' CA
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.0915)(b1, indicat = Floodplain, indicate Floodplain elevation: y~,ft
PROFILE DESCRIPTIONS
BORING TOTAL PTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED ES HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- dos "FF ~Pjs N,)'Bn ~s. a 1 e6.
B- / 'Sirs 3 u
B- %d 9y s N G pf / %~/S/ 1-r ~ n rite v c
Alne
B- s- k 99.E I'Vp s w
ftS~.
B-GlPV• 9d •D
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD 2 P PER INCH
P S r
P-
P- Z 6 /V /k t 7 `r Jr-
P-
P- 3 5 2 ALI .3 31
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 sl pe.
3:F/
SYSTEM ELEVATION A
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures nd th specified in t i nsin
I Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belie 3 Z
NAME (print): TESTS WERE COMPLETED ON:
DAVE FOGERTY PLUMBING 6 , Z
ADDRESS: Licensed Pe, k #3233 Teste, & CERTI CA ION NUMBER: PHONE NUMBER (optional):
Foe&M Heights Road
ROBE S, WISCONSIN 54023 CST NATO .
Phone 749-3656
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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REPT131 TROY ST. CROIX COUNTY ZONING PAGE 1
.05/12/93 16:19 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/17/93 AREA: MJ
.Activity: A9300021 5/17/93 Type: CONV93 Status: PENDING Constr:
Address: TROY,8.28.19,NE,NW, LOT 2, RED BRICK
Parcel: 040-1219-20-000 Occ: Use:
Description: 193361
Applicant: DELTA CONSTRUCTION Phone:
Owner: DELTA CONSTRUCTION Phone:
Contractor: FOGERTY, DAVID B. Phone: 749-3656
Inspection Request Information.....
Requestor: FOGERTY, DAVID Phone:
Req Time: 15:05 Comments: ?'36
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
i
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/hAt7TQtCtPfrt+T-Y: LOT NO.: ELK- NO.: SUBDIVISION NAME:
NW 1/ /T;f N/R/y E (o ',~v/ 2 P view
COUNTY: tmrgrR'/BUYER'S NAME: MAILING ADDRESS:
D< c S seer
USE - DATES OBSERVATIONS MADE
I NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
LJ Residence ,3 II~J New ❑ Replace L
Z 8
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIO❑NAL: MOUND: IN-GROUND-PRESSURE: EA SYSTEM-IN-FII,LHO S T : RelECOMM ENDED h VC. 4SYSTEM: (optional)
(~~J2` UU EIS 9U E U IOU u El S Z~P*7 OIL 744 C
DESIGN RATE:
If Percolation Tests are NOT required If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicat Floodplain, indicate Floodplain elevation: ylA[
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.)
B.+ s s y) 'B h s w 1 6 .
B- / 9/ '1315,1
B- 9t 9y.5 NMI / L/S/ / 71n /R/ v ' c
y~ `By Hrt•
3 c c
B- /3S C- e /357 / c w> TA,
B c"/eV. 98.0
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ S r
P-
P- Z Sd > r r
P-
P- 3 sz AJIxE:1 -3
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 41W e.
SYSELEVATION
7 foacl
ID: 71A
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures nd th specified in t i nsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belie
NAME (print): TESTS WERE COMPLETED ON:
DAVE FOGERTY PLUMBING ~ , 2
ADDRESS: Licensed Pe,k #3233 Tester & CERTI CA ION NUMBER: PHONE NUMBER (optional):
FogeM Heights Road
ROBE , WISCONSIN 54023 CST NATU
Phone 749-3656
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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