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AS BUILT SANITARY SYSTEM REPORT
OWNER ~,~~y Gee ~T TOWNSHIP .STJoSz!?~
SECTION T N-R-W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT_~~LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i ~Qw
P~
g `
l~
~ e
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: Saloe a f/~
Alternate benchmark ye'..v,e
SEPTIC TANK:Manufacturer: lyi4Vl, 0-57- Liquid Cap. /0~ o
Rings used:,LManhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side , Rear Ft./,,Jz7-1-
From nearest prop. line:Front..k,, Side , Rear-~LFt. 49! + 4/.1''
No. of feet from: Well All Gc_ , Building: /Z
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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: X- Seepage Pit:
Width: Length 4-5 Number of Lines: :2- Area Built 3
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: "
No. feet from nearest prop. line:Front , Side , Reary_Ft./
No. feet from well: ti w No. feet from building 3 4
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: l~ PLUMBER ON JOB : ra~~
LICENSE NUMBER:
6/90:cj
Ii'sco sin art HU S10 28.30.19 SPlk SE 60TH
SEWAGE SYSTEM County: ry, Labor and I+uman Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 175655
Permit Holder's Name: City E] Village [kTown of: State Plan ID No.:
❑
E T RANDALL & PENNY ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
Aj el
TANK INFORMATION ELEVATION DATA A9200313
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic t , Benchmark /z2i /aO
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet /ip3 q 96, 10
TANK TO P / L WELL BLDG. Ai,ito ntake ROAD Dt Inlet
ir
Septic /-/S NA Dt Bottom
-7, 3 3 / DU. 5
Dosing NA Header / Man. ~S 100-51
rlba /omr A 3
Aeration NA Dist. Pipe 7 y~/ -6o.39
Holding Bot. System 61% Iq
r
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand 6.y6 /613
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS los Z DIMEN I N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O GG f CHAMBER R Model Number:
System: ~Y-W D. 2Ga
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 TE epth Over xz Depth Of _Tx Seeded / Sodded xx Mulched
Bed /Trench Center e d /Trench Edges Topsoil E] Yes ❑ N ❑ Yes E] No
OMMENTS: (Include code discrepanci s, persons present, etc.);
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 6C k;klliq L~*'Al/v~ 6 0 Iv
SBD-6710(R 05/91) Dae pector'sSignature Cert. No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
a
r
ILWR SANITARY PERMIT APPLICATION
v In accord with ILHR 83.05, Wis. Adm. Code DIV Qj At e-~ t
EA:r..~...,..,,~,,.e.
STATE SANIT PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 6-
8% x 11 inches in size. c isi to prey 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
Pi- e%A/11% Zde S: ,E %SF- '/4, S 2 e' Tjj), N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
S8-f r¢ eo •t!/Q
CITY, STATE ZIP,,CIlODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned VILLAGE • ~i~~
IM 4OWN OF: ARCEL TAX NUMBER( b)
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms ~ P
III. BUILDING USE: (If building type is public, check all that apply) na v /a?
1 ❑ Apt/Condo v If
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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. KNew 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E1 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) c ELEVATION
C, Feet U3 v Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
structed
l I I
Tanks Tanks
Septic Tank or Holding Tank 7'` D- F1 F1 I
Lift Pump Tank/Si hon Chamber, El LF] F] El I El
Vlll. 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 PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
r
1
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
Surcharge Fee) -6
PApproved ❑ Owner Given Initial
Azleu
dverse Det rmInation
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: C/ -V
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS '
1; sanitary pprmit is valid for two (2) years.
2.`'- Yobt 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 ey 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. Prop"-owner's. name and mailing address. Provide the legal description and parcel tax number(s) of
where the system .iS to be i~statled',,
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 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; 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. u
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 andestablishment of standards-
,i
SBD-6398 (R.11/88)
S' ~
STC-100 .
This application form is to be completed ,*in full and signed by
the owners 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 SC 1/4 S'G 1/4, Section ag , T.30 N-R'LW
Township
Mailing address
~D11J
Address of site c e V
Subdivision name Lot no. /yAq .
other homes on property? veS- No
Previous owner of property-;
Total size of parcel GJ •
Date parcel was created 4L
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for (spec house)?_Yes _,~LNo
Volume 9L15 and Page Number 2(o 1 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 j
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. Lf Z-0 _ - , 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
propert for
construction of said system, and the same hasbeen,duly
recorded in the office of County Register o deeds as Document
si nature of app rant Co-appl c nt
E
Date of Si nature Date o Sig ~aturi_-
SI'A1 'E 01- WISCONSIN-Itrlt ~l 2
482020 L I6ER 945PAGE 363 THIS SPACE RESERVED FOR RECORDING DATA
~ 'S OFFICE
THIS INDENTURE, Made this .....1-.4t .........day of........_ApT 1-,•-_,,,._.•,_•,-,•„ REGISTERST. CROIrQy OFFICE f
A. D., 19,9.2.., between...._ERICKSMITH...... INC........_........ Rec td for Record
..............................a Corporation APR 151992
duly organized and existing under and by virtue of the laws of the State of Wisconsin, located at
11:30 A. M
at..................... COIf.ax ..........................._-.....-................Wisconsin. Party of the first part and
Raxida11.......J......West. ...and.... Penny ...M_.....Kest,....husband and
.-..Wi-f e
Register of Deeds
partie.S..of the second part, RETURN TO
W I t n e s s e t h, That the said party of the first part, for and in consideration
of the sum of.---.Dne....Dnll.ar....and...-o.ther.....val.uab-le
cons.idera.tion
..........................................................................................................to it paid by the said part.i.eg.of the second part, the receipt whereof
is hereby
confessed and acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents
does give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said part.iesof the second partthei.llbira and assigns
forever, the following described real estate situated in the County of St . -C.rO.
.i.X and State of Wisconsin, to-wit:
Lot 2, Volume 8 of St. Croix County Certified Survey Maps,
Page 2357, Document 469256. Being a part of the SE14 of the
SE of Section 28, T30N, R19W.
"TIM
$ 7a
(IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate
right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy
of, in and to the above bargained premises, and their hereditaments and appurtenances.
To Have and To Hold the said premises as above described with the hereditaments and appurtenances, unto the said part eS..of the
second part, and to.th.eir...heirs and assigns FOREVER.
And the said ERI.CKSMITH.,.....INC.•...........
party of the first ppart, for itself and its successors, does covenant, grant, bargain and agree to and with the said part.l.eS.of the
second part th21r ..heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the
premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the
same are free and clear from all encumbrances whatever
and that the above bargained premises in the quiet and peaceable possession of the said part.._i8S)f the second part,th,&.jWrs and assigns,
against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT AND DEFEND.
In Witness Whereof, the said-- ER I..C.KSMI.TH.,.._INC...........
party of the first part, has caused these presents to be signed by..._....Denni.s--..W- Er-i.ek Son-- its President, and j _
countersigned by its Secretary, at........Hud - son..._.........._..........__................___.,
Wisconsin, and it§ tblporate seal to be hereunto affixed, this.....-4.tt.1.-.--_(lay of._...Apr.il......_ A. D., 19_92...-.
ISICdNHfa{/ANyD EALED IN PRESENCE OF
ERICKSPIITH NC.
r ,
` f
r) to t t i'resr en,
.f..... ;-2
Dennis W• Eric son
• :fir d = x COUNTERSIGNED:
s~A
9 Secrrtery
Hrrrrrgn r n u,..•P~
STATE OF WISCONSIN,
St Croix I -
Personally came before me, this....._ .............day of_...Ap-r.il.................... I A. D., 19..4.2.,
Venni.S...NI......Eri.ckson................ President, and Secretary of the above
named Corporation, to me known to be the persons who executed the foregoing instrument;ltnd to r e known to be such.... -President
......and _....._.....Secretary of said Corporation, and acknowledged that they executed th foregoing instrtiment as uch~office~rs as the
aced of said Corporation, by its authority.
111 1 b
T
~'e.+r,7 Ft a~ agsT
_r.:...-..- y--
NOTARY
SEAL .
This instrument drafted by Notajy~pblic.......- .
d t... - . ..t .X County, Wis.
Renais...W._...Eri.ck.s.On................... My I:$ eion(~Exp e) (Is~~ ~ 71.................
(Section 59.51 (O or the Wlscomla Statues provider that all Instruments to be r-,ded,ift) pl$gl~gr rNld oe tFpewrltun thereon the
names of the &motors, grantees, wltueuee and notary). rr,r •
WARRANTY DEED-STATE OF WISCONSIN, FORM NO. 2 rrr rrrrrr••r•",,, H. C. MnL[n co.- s,,..u,.r
LEGEND
® County Section Monument - Aluminum Cap Found E} Corner of
` Section 28 '
111 Iron Pipe Found
0 11" x 2411 Iron Pipe Set, weighing 1.68
lbs. per linear foot, o o v
_ ■ cli
Ol TO .L+ 7
N VI In
O O N N
O
Unplatted Lands x s co
N
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4, O
'H
OWNER _ N89°04'58"W 300:00' a
267.001
9- 4-
Ericksmith Inc. 33.001 a
P.O. Box 201 w o
V) C~j
Lakeland, MN 55043 co I 66, b 0
0
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FILED
+ +
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M I
MAY 10 1991
o i JAMES O'CONNELL
a i Register of Deeds
I 5L G7,•dx Co., W1
e,
_~i O I N
00
1.~ 1•-( ~7' - mot' v I
SS NY'HA N I Q
N N C I
h► ~ S I • ~ to N I
~Q07 y N 7, LOT 2 W. N o
o1 I r (z] ( w I
UD~pON, >
l , WJ r t
1+1 w I w 411
Wis. co a aI
W W ~ Y. •N I L C I
i;r9N0 ciIRJ~~4'' i 230,023 Sq. Ft. C> ~I o 1 I C>
-r 5.28 Acres Including R/W °o 4-1 N ° o
dlol o d N
APPROVED v.. I O 194,905 Sq. Ft. 1DI N °i
ROVED 01 N 4.47 Acres Excluding R/W 0
O
I 0 rn o
0 CT 2 2 1990
ST. CROV COUNTY
C0VPR9413 61VE PAPKS PLIAIv?e'fr:'
AND ZOM!J - CC>mmrrrFr-.
d
• N
SCALE IN FEET "
v
m
0 50 100 150
I
r
LO 331 331 n
-o
o v
S8704514811E 298.93' 1
---------------------000 N
N
2279.811 130th AVENUE
SE Corner of
S89°0415811E 589004' 58"E 333.67' Section 28
r
S} Corner of South line of the SE- } of
Section 28 Section 28
N
1 _i t _t r__i: t: _J' C....'.. U- 11,.1 F o.,,,, 19W.
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 3 w us -I-
ROUTE/BOX NUMBER ( S ~0 O A, 4- : FIRE NO.
CITY/STATE 4 W ZIP
PROPERTY LOCATION: SE 1/4 1/4, Section , T 30N, R_1!~ _W,
Town of P/1- , St. Croix County,
Subdivision Lot No.
Improper use and maintenance of your septic system could result in its premature
fail6re 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
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
.The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper 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 form will be sent approximately 30 days prior to
three year ttxe,ration.
I/WB, 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 Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date. s
SIGNED
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
r8.
DEPARTMENT OF- REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,, - DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNSHI /MHH'GFPA61-TY: LOT NO.: BLK. O.: SUBDI SION NAME:
1 151/4 /T3dN/R I (or 5, tM s e N
COUNTY: OWN 'S/B YER'S M AILI VGA DRESS:
5 , 5 YQ,
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIA DESCRIPTION: PROF LE D CRIPTIONS: ER LATION TESTS:
,,~~ppResidence ~Oew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
r O®ENTIO~NAL: IMOUND: ~u IN-G0UND-P~ URE: SYSTEM-IN-FILL HO~LDING TANK: RECOMMENDED `SYSTEM: (optional)
S - t1__A_1 71
SIN RATE:
If Percolation Tests are NOT required DE SIN If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: q 8 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTA DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IC OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
I r S/ • 13 fir. Si/ . .crap S 471P.., .5 T -rT
'~!1
/ , /7rBrs~ -5/0 A S 7O~';daS
B- 2 o~z S ' 7J
33 •7 s, -7 -?J? mc, s
B-5 ~6 o, > q 4-7 r
Jk2 -4 7_7?
B- 70 > ;70
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH
P-
P-
1VIJ IT
P
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. j
SYSTEM ELEVATION 99, S
3
l
E
i
4 a
E
II ~ 3
_
E
33
T
o
r F o
1, 2-
0 35i i t,, l
3
- - -
l
dl-
8 p~ t N
- .Q ! - q ;
0f
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord ( su`res and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WER COMPLETED ON:
X44t,/ Sn 4-k I
ADDRESS: CE TIFICATION NUMBER: PHONE NUMBER (optional):
/2 3 ys t/ s~ 3
CST SIGNAT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) -OVER -
11"'TI I, DTIONS FOR COMPLETING FORM 115 - SBI - 6395
To be a c mil Ord accurate soil test:, yokir report ~rclude:
1. comb ~cription,
2. The use c clearly ind v er this is a residence or- commercial project;
3, MAXIML i of: bredroE r, zrcial use planrtt;el;
4. Is this a r
5. Oomplc_ A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL ~
OTHER _ (STET' RULE", i-UT BASED ON SOIL. CONDITIONS;
6. PLEASE usO the ate _tions shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEOIBLL c n accur)tely locating your test locations. Drawing to scale is preferred. A
separate sheet may b4 us, if d-1-
S, Make sure your benhnir 1,,-k and ~ l elevation reference point are clearly shown, and are permanent;
9. Complete all appropriate boxes to elates, names, addresses, flood plain data, percolation test exemp-
tion, it appropriate;
10} if the informations (such as flood elevation) does not apply, place NA. in the appropriate box;
11. Sign the 'Form and place your cr:: f address and your certification number;
12. Make legible copies and distrib€ as require(:l. ALL SOIL. TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil St gates and Textures Othe, fmbols
st: - 1011) BR ;k
cob ( • 10-) 3dstdane
gr C { ,ncler 3") - TleStorse
l'r Nigh Oroundvvater
P (olation Rate
s Loamy _td C7rr~~: r
`sl e,.rncly Lodrn Less
L any z3r~ - Mov:;n
sif`;r°r BI Black
- Cry Gray
y 1`
so 1 I am R
sic! L =T, rnot sttles
st - f :-y s ;j vv,
r,
sic ffF - fetiv, is ir; -1:Y S
.7
c c - c -)rr,
pP1 nuns F rl r-
d distinct
p prominent
I-I111L High water level,
six surface water
BM - Bench Mark
VRP _ Vertical Refemrice, 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 submitted 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.
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REPT13k ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1
10/29/92 17,:31 REQUESTS FOR INSPECTION WORK SHEETS FOR: 11/ 2/92 AREA: MJ
Activity: A9200313 11/ 2/92 Type: CONVSEPT Status: PENDING Constr:
Address: HUDSON,28.30.19,SE,SE, 60TH
Parcel: - - - Occ: Use:
Description: 175655
Applicant: WEST, RANDALL & PENNY Phone:
Owner: WEST, RANDALL & PENNY Phone:
Contractor: SCHUMACHER WILLIAM C. Phone: 386-3121
Inspection Request Information.....
Requestor: SCHUMAKER, WM. Phone:
Req Time: 09:11 Comments: IF 1.136
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION