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HomeMy WebLinkAbout020-1147-30-000 Q y v 0 i er O~ ea M ~4 ~ I c I r, I C I C I N zo N ~ X In N O L a c ~ N C O Er Y c C Z (n U. c co o m I i 3 c~ > Z N W O> U) .r O a 71t p z d m 4) N U) a co I o z c avi Z d ° N H r- ~ m C ~ ~I ~ v i _~V N CL O N O 00 00 • m p_ u -c Mo N N I c c O 0 0 2 Q o O N N Z H Z Q O o o N Z Z l N N p N j _0 m r) a> O w y ~ d N T 10 V) cn 0) P I- F- 0 3r 3: 3: ~1- LL ►i O O O O • ►.,i a a a ~y a = ►`1. 'a g O N > N N N y~,~j fA J U > rn 0) 0) rn } O (0 M O (0 r- O O ~ ~ d n ~y r 'a N Q ~ m ~j G' r ~ YO Q i 'n V) O O V) C O c =5 O lf) N 00 3 c c 70 rn °o L r H c cn N Y ` N Q 0 O _C:' C O r Z (D C) O C\3 _0 m • 7~ O N S r O - N H CO I CL r cat E .c c c u a 0 to ci AS BUILT SANITARY SYSTEM REPORT OWNER f TOWNSHIP fdYt SECTION-2j~_T_ ! //N-R-_e~j? W ADDRESS ~~~~sf• ST. CROIX COUNTY, WISCONSIN SUBDIVISION S LOT~ZLOT SIZE Z. PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /o ~ u z 6 r r r fca ~ r~ f 3 v ~ ~ f ~ a~.~ f©o. D 9 7 Y' fe-, e' 97o " INDICATE NORTH ARROW ~ r BENCHMARK: Elevation and description: ` lBd 0 Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. f / Rings used:-,~2-Manhole cover elev: 00.6 Final grade elev: /GAD Tank inlet elev.: / L Tank outlet elev.: /Vel 7 No. of feet from nearest road:Front , Side✓, Rear Ft. 7 /S?i-' From nearest prop. line: Front * , Side--Z, Rear Ft. > .rV No. of feet from: Well &Iet , Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE ~ j PUMP CHAMBER Manufacturer: 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: L Z Seepage Pit: Width: _-Length 45- -Number of Lines: Z Area Built.4,:S-Q Exist. Grade Elev. AINgVe _Proposed Final Grade Elev. n ~r Fill depth to top of pipe: ? y - ? G No. feet from nearest prop. line:Front , Side , Rear_j,~-Vt.~S::- No. feet from well No. feet from building .5-'D HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building nearest road Alarm Manufacturer: INSPECTOR: DATE: ? 3° PLUMBER ON JOB: LICENSE NUMBER: 9 6/90:cj L Quons~ilCfepartfigntDo~lnOdust 26.29 .19. 7P jIQ,eftIA & SYS~TEMADOW DR. County ry, Labor and Hurgan Relations INSPECTION REPORT Sat`ety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 171452 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: DELTA CONSTRUCTION HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 1 00,0 1D-1,33 io a raw; I` b 3-< +r - 1 020-1147-10-000 TANK INFORMATION ELEVATION DATA A9200217 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic <S 00 0 Benchmark t v 7,3 3 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 1~3, j TANK SETBACK INFORMATION St/ Ht Outlet 107" TANK TO P/ L WELL BLDG. verntto AirIntake ROAD Dt Inlet Septic so / Nth 3 g NA Dt Bottom Dosing NA Header / Man. I 42 q"I.CIb Aeration NA Dist. Pipe I q ' 8 1 112- G .l 9 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade I ~D I (12. 99. Manufacturer Demand 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 Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S co 1; DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O I I Mode Number: System: Is so g' Pr CHAMBER OR UNIT DISTRIBUTION SYSTEM Header/Manifold I~ Distribution Pie I 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 r x Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edge Topsoil 1 ❑ Yes ❑ No ❑ Yes ❑ No t o COMMENTS: (Include code discrepancies,p sent, etc.) V0 T k r ~ f Plan revision required? ❑ Yes ❑ No Use other side for additional information. 3+ y/ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH r ' SANITARY PERMIT NUMBER: 7,33 0,+iet 3' to 3,_7 t CL V." 0 v lz-8,31 . 98,5L F.~a~ p 0 4 = 10,33 - 1 '1• 1 1~c7'y'/N=73s:9918 Iz 9.37.57,5A Ira- q '`iI _ x 01~-HR 5 SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STAT SANIT YPERMIT# -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /'1 / q5-:Z 8% x 11 inches in size. C eck if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORM TION - PLEASE PRINT ALL INFORMATION. PR R OWNE PROPERTY LOCATION '/a t/4,S& T ,N,R /9:~ E(o PROP RTY WNER'S A4'ONG ADDRESS LOT # BLOCK # .Z ~ /7 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NA OR CSM NUMBER c~• 6 "rd, 6 ~s II. TYPE OF BUILDING: (Check one) CITY NEAR '~AROA~~ ❑ State Owned ILLAGE Public l 1 or 2 Fam. Dwelling-# of bedrooms -4- AR TA NUM ER ) ❑ III. BUILDING USE: (If building type is public, check all that apply) / 1 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 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. EO L~ New 2. ❑ Replacement 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 19 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 S13 .5' j ~j i f' ?l I Feet A01- p Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank ?Are -F e<A l 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. P ber's Name (Print): au! Z- a~o tam ) 'MR/MPRSW No.: Business Phone Number: rt 7: _Plfimber's Address (Street, City, Stat , Z' Code): ~a lr-~ IX. C UNTY/ EPARTMENT USE ONLY ❑ Disapproved Sit ary Permit Fee (Includes Groundwater a e slue Issuin Agent Signature (No Stamps) Surcharge Fee) / Approved ❑ Owner Given Initial &_111 a Adverse Determination ~v 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. You r'sanitaryipermit 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 (S130 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete 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 fc c all septic, pump/siphon and holding tanks for this system. Check experimental approval only c anks 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; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. - SBD-6398 (R.11/88) STC-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 Location of property 1/4 1/4, Section T N-R W Township Mailing address Address of site subdivision name Lot no. 1. Other homes on property? yes_2L_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 No volume and Page Number 3-3 as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUVITY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. certified survey, if available; ;would be helpful I o asd toi 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 1(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 the office of the County Register of Deeds as Document No. ``ff'' /s~ , and own the proposed site for the sewage disposal t 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 reco d 'nom j office of county Register of deeds as Document No. S`7 2Signa-turr o a ¢licant Co-appl cant Data of Signature Date of Signature F THIS SPACE RESERVED FOR RECORDING DATA DOCUMENT NO. it WAP. ANTY DEED STATE BAR OF WISCONSIN FORM 2 - 1982 PAGE 484159 VOL 953 332 REGISTER'S OFFICE GLENN WAXON a/k/a Glenn A. Waxon and VYCELLA_ M. WAXON_ $T. CROIXCO.,W1 a/k/a Vycella S. Waxon a/k/a Vycella Waxon, Grantors ReC'dfOrRecofd . . . - JUN O 21992 - . . conveys and warrants to --..DELTA -CON S_TRUCTION. -COMPANY . 10:50 A Of M ...a.Xi.nnas.aka..corp.orati.on,...Grantee................... O'&'>''UV "W 'ta ~ Register of Deeds - - RETURN TO . the following described real estate in ........St. Croix County, State of Wisconsin: Tax Parcel No: _ a - . I.. - 6 Lot 17, High Meadows in the Town of Hudson. i. tl~, X", F ED II 11~ FEE II TOGETHER WITH AND SUBJECT TO reservations, restrictions and easements of record, if any. is not homestead This property. 09) (is not) Exception to warranties: Dated this day of June 19.92.... (SEAL) A,&.,,~ -..........~ti (SEAL) * GLENN WAXON . . . - - ~ . (SEAL) ...................(SEAL) . . - * * - VYCELLA..M....WAXON AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN ss. St. Croix i County. authenticated this -.------day of--. 19...... Personallcame before me this s ....day of June 19._92 the above named . Glenn Waxon and Vycella M. Waxon TITLE: MEMBER STATE BAR OF WISCONSIN (If not, •P LI --g authorized by § 706.06, Wis. Stats. B }~r~~l"_'!~~ ~ VWknown to be the person S--......... who executed the d e the same. RR t~77OTARY UBLICr%oini.nstru THIS INSTRUMENT WAS DRAFTED BY 'B't~*'PFW:''ISCONS~ Attorne Barr L Lundeen MUDGEPORTER & LUNDEEN, S-.-O-------------- 11Q..SecRnd..StxeeC.,..Hudson-,_•WL.54016---_--_-- Notary Public St. .Croix County, Wis. i (Signatures may be authenticated or ackiiowledg•ed. Both My Coi fission is permanept. (If not, state expiration are not necessary.) dote: - - I !K p~ 19/ - - - - •Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. • • ~ ii;l"i~vi i'3wfi1o~ ,i ~ ~ Y ; ~ 30NG~jy d~ C Z . • Y M Gel z3 e iL! . is ~ 7 • IY -i • L« ~ { p Z -Ii , a. ~ r••,tla etc• 11 `•~1 ~1; O I f •tt . T •g, ,,.1~, i,ee.ted r 7: T I • Ni S 11 T~ ~ ~rf 1 ~ t Ti ►i f1 ~f une rs.teet C Y' P~~,'N 1'•~ 0 t~ ':r es el YI 1 1\ fj C I• •i ~ LL fail, I \ .0e i" ,It tl{.' • o r 1 ~ ~A r,~,~~ . ttet--i.ae.te.et•-• f. '1 ~j CO' x. m Yi,, ,'fr ej{r 4e~f •rI tD jr i\ Z w 3 ,I t well to, • W 44 Z 'r• . ' ' c;o ro. N C •p WHO a r- CC -too c e ;io -0 -2 0 H ` _ Vr«Yw s 'I I • 'err Je•..1 Y~ ° „ M ° .I I ♦ . .DIY t yr=- E o ° N n V! see °e ea u ut «,tldl.e r SI it t {r » «,u.u.e « I 0 1 IL 0 -to 0 in d tV p `v C $ 1 it liJ 'I F • 0. cc Z s Eel' c i 'go c~ o ao ~ it j '.I'l x•~ 1 p 3 ~44 G = ; Y 'N sa` Y I'•.ee tN....w.t1.N.° r '1= 7t 00 -0 a q J i ti l i E,i 1, a c ii • si!}i I _ 1•~ i p 5e E T! ► t ~I • i 1 •i e►ei)•)r)nr t{••w)t e)•~{{r ;a;T :I _r 1 it ;f i, -.t• ttf. - legit w•tl,tl M MI it • fw{ tt;~ it it:df ,s;.fl it; :ii{:: eiiiiiiin 1 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Lit t~~ ADDRESS: Zr ~ , - 3~ FIRE NO LOCATION: 1/4, 1/41 SEC. T N-R W, TOWN OF: ST.-CROIX COUNTY SUBDIVISION: LOT NO. - Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the replacement of a failing system, which was in operation prior to July 1, 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating 'condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: i DATE: J St. Croix County Zoning office 911 4th St. Hudson, WI 54016 DEPAriTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS "INDUSTRY, DIVISION 7969 LABOR AND PERCOLATION TESTS (115) P.O. BOX 3707 HUMAN*RELATIONS MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP NVJ##+FeH1A-c: LOT NO.: BLK. NO.: SUBDIV SION NAME: w 1/4 '/a /T~ H/R E (or, - s 14, CC'S BUYER'S NAME- COUNTY: MAILING ADDRESS: /7 f 16 ^ _f o } Lro F DATES OBS RVATIONS MADE USE PROFILE DE CR PTIONS: ER OLATION TESTS: NO.BEDRMS.: Comm ERCIALDESCRIPTION: Residence > flew ❑Replace 3 3~ 2 18 Z RATING: S= Site suitable for system U= Site unsuitable for system FCCONVENTIONIL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ES❑U ~SC~U CNS❑U ❑SCt 0SEDO 1- 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: A Floodplain indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13- B- 2 05' o l / ;t.Y~ /,s -Z 12.,,4,h ~,411_91 , r [s w I 9, 5 ml( B- 9 O/r > D . !u w B- 2l G > s i /03. o X PERCOLATION TESTS JP - 2- O . 6 TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATTER INCH ES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER P- Z t ? e ? 7 r' r PLOT S~^ /✓dy G 9' rP,--- PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. p e I S ,1o SYSTEM ELEVATION ~0 v 7 ,_,_A~ ( /O WL(9G'( ° /IN'I .SN MI oHa. A m 9YOfaIc~~'h_l~PVry _ g-..., r _ ~ r} _ . _ W ~a~' ~ kC 4y ~~+c• i r!!+Gts~_ s!p~t`F:H~- _ - p a = _pc,rk ~Io `ca i i r ° 'k 2- /V W (or~ nev, 7T 4 e P'aP Tel fad w~ s x o' r /a ~l I, the undersigned, hereby certify that the s it tests reported on this m were mad y me in accord with the pr dure methods spe Wisconsin Administrative Code, and that the data record d and the location of the tests are correct to the best of my knowled d belief. 9 ~Q r NAME (print): S WERE COMPLETE DAVE FOt~E PLt~MdA i ADDRESS: #3233 #32$9 CERTIFICATI NU PHONE E tnional overty ROBE S -WISCONSIN 54023 CST s N UR Phone 749-3685 //dSoil DISTRIBUTIO N: Original and one copy to Local Authority, Property Ownter. DILHR-SBD-6395 (R. 10/83) F> 3 ti i~ s ;H `O THE C3V!NERF 4.,: . ,.PEirAI,rMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, _ DIVISION LABflR AND PERCOLATION TESTS (115) P.O. BOA 7969 HUMAN RELATIONS MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MAY: LOT NO.:BLK. NO.: SUBDIVISION NAME: w /asp '/4 /T~ N/R /9E co N~sa~r i7 r COUNT'- /BUYER'S NAME: / MAILING ADDRESS: ✓T. ~~X P 17C71 O ~~S GsJ~.. GfJ - D zg; USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCR TIONS: ER O ATION TESTS: I Residence 3 New ❑Replace y Z L y/ 1 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)/ s Xl6 CC'S ❑U ❑ S ❑U EaS ❑U ❑ S CCU ❑ D If Percolation Tests are NOT :SIGN RATE: required If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicates -3- Floodplain, indicate Floodplain elevation: y/~ 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- e /~f1lC > / / s , 3 n ,C J. w 3. ' B- '21 r > JP 1 2 61, y We- S es -7 '5 -7 ?Of B- p2.(f ' G, G" ,3 ,t3/s/ .7 '1.~.. , d ' s w 2 •+7 s .t , ' n n, s . B- O PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P P- p- e f r C ,,,1 S P_ P- 3 o c P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and.the direction and percent of land slope. * e lel' t- t /30 `CfE I Ccr NrY SYSTEM ELEVATION Z • 3 E , T•Y . i,a./ / serve ~ E 17 o p.r. k \ m E i 17 X \4k~ 1 E F' E E See ~re 1, the undersigned, hereby certify that the soil tests reported on this form a e ~j 1»e,in accord with the procedures and methods specifie n the Wisconsin Administrative Code, and that the data recorded and the location of the e 1&, t¢' Tt1S b of my knowledge and belief. . `mo't:` DAVE FOGEMY PLU. fl. NAME (print): STS WERE COMPLETED ON: licensed Perk Tester & Plumber #3233 #3289 Al. ADDRESS: Fogerty e [htS Oa ' GEPTIFICATION NUMBER: PHONE NUMBER (optional): ROBERTS, WISCONSIN 54023 N ' > t PHIsm, 04 $656 A DISTRIBUTION: Original and one copy to Local Authority, Property 6w, erpand Soil Testert DILHR-SBD-6395 (R. 10/83) -d'Ef~ 'n 1- 3TRUCTIONS FOR COMPLETING FORM 1 °15 - SBD - 6595 To be a corn . 0 accurate soil test:, your report must include: 1. Complete leg. 'on; 2. The use section ar€clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bediDOMs or commercial use planned; 4. is this a new or rezclarr ,-ent system; 5. Complete the sui?abi"t rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEM `a F jLED OUT BASED ON SOIL C ONDJTIONS; 6. PLEASE use the s Jiown here for kvritinq profile descriptions and completing -the plot plan; 7. MAKE LEGIBL ~ curately locating your test locations. Drawing to scale is preferred. A sep-r. may iy use f , I 8. Make your benchn ark ad tical elevation reference point are clearly shown, and are permanent; 9. Comp all appropriate boxes to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood ` `n, elevation) does riot apply, place N.A. in the appropriate box; 11. Sign the f€tr€n and place your can _ _.'diess and your certification ne€mber; 12. Make legible copies and distribute as regUi€0d. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures r Symbols st. Stone lover 10"i 8 Bedrock cob Cobble (3 - 10"j SS Sandstone gr Gravel (under 3") - Liar{ to s A High r Cs C, Sand F rraed Sra€7c1 Well fs BL)ildirag Is Loarny Send - Greater 1 han sI Tandy Loam Lass Than 'I Loam Btu Brown sir Silt Loam BI Black ss - G y Gray c y Learn Y all' ,(1l uy C=ay Loam F sicl - N Clay Loam rnot sc Sunny Clay VVI ~ sic; Sil y Clay fff 1 fine, faint `c ° c ct_,,rmrnon, coarse, pt - 11)rn Many, medium rr9 d - distinct P prominent Ili. High ww ar ' Six ger-'- toxtwes surface v., for =iq€., spos rl E> Bench Mark V Jei tical € efeience Paint TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit, The sanitary permit must he obtained and posted prior to the start ofany construction. oM ~ w f 4 I v j' 11 + a I~ al a o L lie t I 1. at -41 OZtC memrl~Z~;~ ~ a ~ ^f y fo0T i m N ^ 1\ 0. n a t~ M_ m ~ o ~Z ~ o p ow _ 1! l ~1 ~1 ~I it II II Vi o k o C ti 3 IS Q~ Z ~ U y ~ SC, x s K V / ` O 3 ~v o h ~p M "1 ~q o4 ` M i a.I _ a V ~ M s a T K _o M v ~ o~ o M ~ t v y ~ it ~I •i it i~ i~ i~ olga: v\ N M X. d Rif ~ ~ v I Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD 'ROBERTS, WISCONSIN 54023 (715) 749-3656 ti ''`,4. - ~rtQ1 - 'F . w _71 Ffs lew, s~/olpe o t' ~rB~~ " yd Cor 1 the REPT131 HUDSON ST. CROIX COUNTY ZONING PAGE 1 07/30/92 10:32 REQUESTS FOR INSPECTION WORK SHEETS FOR: 7/30/92 AREA: MJ 'Act'ivity: A9200217 7/30/92 Type: CONVSEPT Status: PENDING Constr: Address: HUDSON 26.29.19.782,SW,SE, LOT 17, MEADOW DR. Parcel: 020-1147-30-000 Occ: Use: Description: 171452 Applicant: DELTA CONSTRUCTION Phone: Owner: WAXON, GLENN N Phone: Contractor: FOGERTY, DAVID Phone: 715-749-3656 Inspection Request Information..... Requestor: DAVID FOGERTY Phone: Req Time: 13:07 Comments: Items requested to be Inspected Action Comments Time oExp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION