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HomeMy WebLinkAbout020-1186-10-000 ~ i t~ 03 6n I h N ~ c I c O I ~ I o N o I ~ I ~ I c ti I ,1 I I a ~ I z° ° c ii o il' 3 v ~ I Q c I Cl) Z N W E U) O I - o ~ v Z € m c~~c3n I I 0 I z a c c .N. o Z o d C to H ~ ~ N z I M j~ N O O ) C z m z Q N z N ~ N ~ N E o N I I > a w ~ y N aci O N c d i O p c O D d N EI t cotroCOoto o o I r'N '033 a'u~ a Z a o •N aa y CL U) J V U) C,4 C,4 ai (n rn z v r r C O Y O N I J ' c a N N W C 'O co tN/`J 4f Q cn f0 J 3 I rn J U) to ° o O O N C 'I CO U N 0 d ~ to r- LO I ° p c a c n' rn °o m C .N-I O C M r C M C 0 v v l C of 0 o0 M S CD v H c m co *4 Cq .0 N • O N S ! r O Z N z:9 rd (n I r a at ~ = E v ~ a o d ~ as r`1~i y E c c 41 I r A ciao ii,0 ai0 Y FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S A V1^ YVTI L ~ F R TOWNSHIP 141.Lsg© y\ SECTION o~ T a N-R W ADDRESS Ba k, 2 6 ST. CROIX COUNTY, WISCONSIN SU13DIVISION_®~41' LOT LOT SIZE 3 16 9 lf~. PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p~e ; C.~' to Jo. vV1QAd v ~,p h; I1 (Q V ~0 / c V I n a1. _ b a _ WE/ ) 46 H _ CC A y ,x 3 2' • pr? Jcw,y B.M. I~ I~bN i~;p` I >r 1.= IOO.on~ INDICATE NORTH ARROW BENC1iHARK: Elevation and description:/ %,eO# ?,4e_ CF/ = 40-0x J' Alternate benchmark 0.7-6' SEPTIC TANK: 1•1anufacturer: We e,~ Liquid Cap. 100492gl Rings used: L Manhole cover elev:'F: ZO Final grade elev: Tank inlet elev.: //,VZ Tank outlet elev.: /1.73 No. of feet from nearest road:Front X , Side , Rear Ft. ,30From nearest prop. line:Front , Side X , Rear Ft. No. of feet from: Well $ - , Building: . 7 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE t Y PUMP CHAMBER ~~//~J Manufacturer: ',Y/r Liquid Capacity: Pump Model: Pump/Siphon 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-;72-0S?-77- Exist. Grade Elev. % S-4 -Proposed Final Grade Elev. /(.Z O Fill depth to top of pipe: y z No. feet from nearest prop. line:Front Side X Rear Ft.3.5 No. feet from well: /oS" No. feet from building ~/4 HOLDING TANK Manufacturer: 4/A 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: 6/90:cj LOCATION: HUDSON 21.29.19.1172,SW,SE,SEC.21, LARSON LANE Wi9comin Departmehtof Industry, PRIVATE SEWAGE SYSTEM County: Gabor ancj HuLnan Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.. GENERAL INFORMATION 149303 Permit Holder's Name: ❑ City ❑ Village)[] Town of: State Plan ID No.: BENOY VERLYN E & CATHERINE HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020118610000 TANK INFORMATION ELEVATION DATA A9200144 0s Z TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Aeration Bldg. Sewer Holding St/ Inlet yz, 91.-21 TANK SETBACK INFORMATION St/~Pt Outlet 9/. ' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 22 NA Dt Bottom Dosing NA Header/- ~ t Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 12, 7'~' Manufacturer Demand Model Number GPM y; 5f/ 3 s9 TDH Lift LOSS Head TD~yste H Ft 127 Forcemain Length Dia. Dist. To II SOIL ABSORPTION SYSTEM BED / TRENCH Width Length , No. Of Tjrenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ' / DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O C6q,), CHAMBER Mode Number: System: 9-_ U 3:!~~, 144 , OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Z/ Dia. Length Dia. __s2: 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/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes BNo Use other side for additional information. 19115-- 1 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' r , E , '4~ ~ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY Oit e~ STATE SANIT%RY PERM # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~y4 8% X 11 inches in size. eck f revis on ous 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 So I (i-r ! Cath4.ri a. iscna SWY45LG '/4,S 2 TZ9,N,R /I E(or PROPERTY OWNER'S MAILING ADDRESS LOT # / BLOCK # 4 6of- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER s IV 3 v y3 Pr..cr', e,Wsfit CITY Tj1$..6,n EAREST ROAD 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE 4OWU OF: GC S 0 01 L eu1 a_- ❑ Public ~0 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL AX NU E RL c.,/ w 7 Z 111. BUILDING USE: (If building type is public, check all that apply) D _ / ID 1 ❑ Apt/Condo L/ ~O 20 Assembly Hall 60 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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 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 to Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Valilt Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. 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) p ELEVATION ys~ 72c) -7ZO Q.#oZ.s < 3 YO Feet ~9•8o Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App I Tanks Tanks structed Septic Tank or Holdin Tank /600 :4a.r F] I D F] Lift Pump Tank/Si hon Chamber F-I Ll El F-1 I El El 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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Dom. Stroh bd_Av, I M P Sy 3 Z. If ZN7 IaY Plumber' Address (Street, City, State, Zip Code): Q * Ha.W , e-V, I S-qC)j-j IX. COUNTY/DEPARTMENT USE ONLY 4 7 ❑ Disapproved S itary Permit Fee (Includes Groundwater a e Issued Issuin Agent Sig re No Approved El Owner Given Initial Surcharge Fee) ] Adverse Determination LL5_ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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 adrnmistrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. 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 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. Ill. 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 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; frict on 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) ` \O . T a La s a J Q} a~ Q _ as ~'A c - , ~ C 'o r4 O~ S N a 3 r in J Q~. d 0 = d i M Q S , 1 dk A vi 0 ~ r Q U * cr d fr ' b t' ' CQ\ mac` ' M ~ ? VI ~Ib 1 N / S M ~d r 1 C N OC '1 I ~ 0~ ~ o J t ~ q J ~o o~ ~j dJ r d 4- O vi -i a 7 d' ~ T J t ~ ti • Y > x Ls F-- ~ ~ O ~ ~ O Qom' < °t- CL o t CL t! j U Z ii lil I :1~ W I I a- I i~,1 I U ~t1 lik 1 s' i 1,~ 1=1 ~ ~ 114 li((~ t ~V tl w w f ~~f Ili (iI E-L UJ I ( ~I 111 i U U I14 Lo ifs ~ ~j I~ I w > U Ilf ICI ; 0- L silt III E ~ r II I, t 1"~ ~i 1 I I 1 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 Sa rn //a,! f,~ << M - ~~MOy Location of property _S W 1/4,5 b 1/4, Section N-R /7 Township ~}h-'`sort Mailing address Me' '-I..A w De-; rte ZT.0 . r Aoj r- 16 14 Address of site Z f ;v'-/SC 41San G4 . Subdivision name ~~,~;r,~.. Lot no. Other homes on property? yes No Previous owner of property A/dro L.~iseh Total size of parcel ei".-5 Date parcel was created 3/3//86 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? )(Yes No Volume 73-1- and Page Number ySs 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 the office of the County Register of Deeds as Document No. 4//0y2/ , and that I (we) own the proposed site for the sewage disposal system orr I e(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. r Signature of ap~lican Co-applicant Dat of Sign t ure Date of signature -n ._~--•-----'^„z..-. +N:, r :.-..-,r-, • '':-.te. • ; DOCUMENT NO. STATE BAR OF WISCONSIN FORM 5-1M TNIe SPACE a[e[IW[D IOA PERSONAL REPRESENTATIVE'S DEED 410421 Harry J. Stewart N~)~r Co r W{~, . . ii ..........-.....e est to o k: fE+lUt'~ l~115 31Pt . as Personal Representative of the estate of March aJ A.D. 19 86 . 9:45 A E:~L ("Decedent"), for a valuable consideration convoys, without warranty, to • .Verly . E.. -Benny and Ca therine__A...Beno as.-husband--ard- wife--as- marital-- f 9wt'Ir oa a"d4 Yom..... ro ert w[th ri h of sur- • P........._. ncTU To the following described real estate in -_SC. Cr~ix -------------------County, State of Wisconsin (hereinafter called the "Property") : West Half of the South East Quarter of Section 21, Tax Parcel No: Township 29, Range 19. Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this day of 'ltlrc.l) 19_.$6... -4- r~r~::........... . . . . . (SEAL) - -•--••--(SEAL) . b M % Prrson❑ S,,V-nt tj--Y" 4 Penonsl ReVrnentdive C U Jr AUTHENTICATION ACKNOWLEDObirM,T0 CJ' ` 7` Q l -77 Signature (a) STATE OF WISCONSIN f ' 47 _.Gount authenticated this day of........... 13.. Personally came before me this 26th...day of Max s))_ , 19. H... the above named Ilarry..,l._.Stewart,. as I)ersUipreentative _ f.~?>; t11e -est~lts..clf_Jul)n Aldro-MyXgn -La•;sen, TITLE: MEMBER STATE BAR OF WISCONSIN a/k/a John Aidro .Larsen,, a/k (If not.. Larsen authorized by F i()ft,0r,, Wis. Stats.) to me M oa'n to he the person who executed the for it instrumeut and II %viledge the saute. THIS ~N TRUMFNT WAS DRAMI"D r'.v l Lois A. `turray of 116YW001), CAltl .P.4. L'ox llutisua, 1;1 3401-6 Noel-> 1'uhlir St. Croix County, Wis. (Signatur- olav ho authenticatorl or arknnwir.l: rl. IS.Ih Nly ('nnm,i.~;ion Is permanent. (If not, state expiration arv not u--ni..l T , 13.r7.~ date: ku •N.n„s .,f i,.r., .ICnlnv u. n r. 1.. ~ ~ ~.i.,l L..I„,.. ~t ~i ni \II It Alt OF WIS(nN.1lN Wisr•.nsin I.rKnl Thank Co. III,, 5 - N2 hLlwsukre, Wis. PERSONAL REPRESENTATIVE'S DEED 1 0101 Nn. 19 r SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_ Se• M Mi //a4r e,471Al^ri Au- Ae'1014 ADDRESS : 744 /Yla.4-JO LO Dr; ✓ 4 FIRE NO: LOCATION:- S k) 1/4, S,6 1/4, SEC. 21 T k I N-R /rr TOWN 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. SIGNED: I. DATE: 1.3 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INCUS'TRY, P.O. BOX 7969 -IfABOR AND PERCOLATION TESTS (115) HUMAN RELATIONS MADISON WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP M44N+6+FA++T~: LOT NO.: BLK. NO.: S DIVISION rj~j~A w 1/4SiE 1/4 Z l /Tz9 N/R f E (or) W / COUNTY: OWNER'S/BUYE S NAME: MAILING ADDRESS: S go rA, Swrn m jLt.&A USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DE RIPTIONS: irtri 0 ATI N TESTS: Residence C4N - - (New ❑ Replace 9 9 Z 1~ /Q q Z RATING: S= Site suitable for system U= Site unsuitable for system CON ENTIOaNAL: M" NO: ❑u IN-GROUND-P URE: SYS 14S I❑ULHO❑LDING TA K: R680~M`/ENDED SDY~A flop ion~►, If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Cu4~5 Floodplain, indicate Floodplain elevation: N4 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH Vla ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- I CI AZ /w3~ d N > q •qZ 8 "$~sc-rs r? "61v►~S c. Ys~s' BeN ~h S Grz B- l0• ~7.1-7 r4eNE 7 /O~s~ ~3"g~SGTS 3S $Qti/►~ 7g"'B rhS G~2 B- 3 10.33 903Z No /v.33 3o"$cs~~-s z3" BaN S L 7 ~"ga~„r►~►S~rGI~ B- d 9z~ Z.63 No1.1~ 25~Qcscn -Zcr&,IsZ.no$w~►~j;:Lh 4-6.0& ,ft B- NoNe( ~,~~5 2Z-~~$CSC`f"s ~1~'$aaSL~b~'BQN 1~t~68~eRnrlhS~41I~ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 6p6611PU~ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P_ .zo 4dr41K 11 9 b D 7 < P- Z 6 rlo 4.Ib ?2 > > <3 P_ 3 J400 ~0 6 > < P- P_ P_ PLOT PLAN: Sho 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 vation 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 ELE TION ( a IL(_ w _ I E E E ~ Clu _ uP~_ S1 , l C _ - 3 E N i 3 E P L(- ,.r'c I I too I _ .l._. i 7 _ _ i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord th tF~ie cAedures 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 knowledge and belief. t): TESTS WERE 5ZI PLETED ON: N,J gv~1 J0)4 QSa1.! Q*Wv) &A L / /99NZ- NAM Z,' ADDR SS: CERTIFICATION NUMBER: P NUM ERloptional►: ul~so~ LlIji bc,ok~s),J S'4o1~ :94 f4 W6- 4OW CST SI TURE: 00 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - I' r ,TRI TlO lS FOR COMPLETING ~ M 115 - SBD - 6595 To be a c'€r~ al cl accurate soil te: at:, v e ui, re port mu" 1. Complete leg ascription; The use section must clearly indicate ~~er this is a ra sip o commercial project; S. MAXlMl, M ni. mbi of bedrooms or con rclal Use plaiin 4. Is this a n- trent systeila; 5. Complete tl.. t- rating boxes, A" nE' IS SUITF,I . A HOLDING TANK ONLY IF ALL OTHER SYSTL I,..ILE Of -;ECG ON SOIL C "71ONS; 6. PLEASE use ;i :ons shown ' r vvi-iting profa - i;ans and completing the plot plan; 7. MAKE A La ,n accurately sag your test loc :ons. Drawing to scale: is preferred. A separate she- if desired; 8. Make sure yot- r : and verti I r, fei ence poir e clearly shown, and are permanent, 9. Complete all app = boxes as to d~ nes, address l lain data, percolation tryst exemp- tion, if approprra~~c 10, If the inf«rrnation << ''ioocd plain, r: } does nc` pia in the app iopriat:e box; 11. Sign the form and DL, crur cu ra.rat your on nu: 12. Make legible copies I distribute as ALL SUL TESTS JST BE FILED WITH THE LOCAL AUTHORITY WITHIN :30 DAYc 1IMPLETIC.N, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st. - Stone (over 16"? BR - Bedrock rot) Cobble (;1- 1€31.) SS - Sandstone gr Giaz~.,' (under S") LS - Limestone 1..;,' H', h C a : Edwater s - d~ state ray :~I ~ t`b e is - Fr' Is loamy _ id ; i .sl - c 'tid`y` Loan) ~ i sc; C , / L.,)arn R sicl Loam Mot sc-idy Clay sir, - silty Clay fff nt Ac Clay CC -arse pt - feat € ill I r n in Muck d -k p P 1AVVL H: j Six geC::i?fe,< for ~m'al BN1 - F , V P ne 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 sr.ibmitted 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.