HomeMy WebLinkAbout030-1083-30-300
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INDUS TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 C DIVISION
N
LABOR AND PERCOLATION TESTS (115) MADISG . BO 539069
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: p, OWNSHIP/M-61 C.fA,4k};+Y: LOT NO.:BLK. SUBDIVISION NAME:
iIJ Sw a /T 3o N/R Cor t' 5 4
COUNTy~ OWNER'S/BUYSNAME: MAILI G ADDRESS:
Sfr Cam' y dot r crr. Sav. o 43 e•,~'o< S A) r Iwa~ W : S
USE DATES OBSERV IONS MADE
t!JO.BEDRMS:; COMMERCI L SCRiPT10N: PR FI P I NS: ~--~i`fIO!~r,_ST~:~
Residence 3 /`„"-ew ❑Replace S Z
RATING: S= Site suitable for system U= Site unsuitable for system
NVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:( ptio
S DU S DU ❑U D S MU D S,Et! ~ ~
Percolation Tests are NOT required DESIGN R ~E: G < s~ If any portion of the tested area is in the
unoer . ILHR 83.09(51(b), indicate: 3 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH 1
INUrv1BER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVE (`.;EE ABBRV, ON BACK.)
B / v
< n~
5 , ~1 Bits . 7.
B- 2- > S '
5~ s -
I B-3 G s /o,)
B~
ITEST DEPTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTER ELLING INTERVAL-MIN. PERIOD 1 PERI 2I~ PER INCH
!P y" G7
IP- 5: 3 y yf.. 3 3 r6 r
P_
P-
P
LP-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scars jr 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 :311 borings and the direction and percent
of land slope.
SYSTEM ELEVATION
3a~ '
t IU /o ~ L.>i~
y .is,
81
2 yo ,
s~ev /,Q041
rrL : /oa.v ,
gyp 35
A. le 1'103 k2411~.v
x = `rc 1 v
\D
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in ac-rd with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the bes my knowledge and belief.
NAME (print): TESTS WE.-.YE 0 ETED N:
iJe -7
ADDR SS: CERTIF C~`T ON NUf BE PHONE N M ER (optional):
ST SIG ~l E ;
i -
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHRSBO-6395 (R. 10/83) 7 OVER -
1
+ A*Pnt+nDeoartmertof Industry ~UIL UtJt_nlr I ivlc nor vit r
d Labor ' d Human Relations 0 Sec .-,-a
_ (Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) I.laotson.:•r -j%*
Page
curtoaawwt ttotavK.oere etreverrt-txwatoeotert r wie,,,a kDOWALiet 0.aoorw.ae
Loren Thompson - - rass utwash N-2% n /a
0"°
7frItt . Croix St. N., Hudson, Wi. 54016 .tale ne "45LOAD 00
~t. Croix 450
IOCA11CH 29 TOwH3M►ArtlaCrALffY tAa FAMILMAltR
DORM NW 1/4 SW 29 30 19 St. Joe h
csul
I F LOT 4 BLOCK n/a sullolvlslom perch Lake Ride aL NEW _ REPLACE
B- 1 Houton Deoth Dominant Color Mottles Structure LImlting Factory LoaangGPD's4. n.
In Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundar Depth Trench god
1 0-11 1 4/2 none s.l. 1/vf/sb mvfr 12/m C none .4 .3
Elcv = 2 11-2 1 r4/4 none 1.S. 0 .8 .7
6.25 3 29-111 10yr5/4 none C.S. /f/s ml 1/f m La none .8 .7
Q-2 Norton Depth Dominant Color Mottles Structure Llmulnp Factory Lot&ng.GPty24 it.
In. Munsell u St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundary Depth Trench gad
l -9 1 4/3 none l.s. f s ml none .8 .7
Elev = 2 -20 -Oyr4/4 none l . s 0If Isg ml 1/f G none .8 .7
99.2 3 0-11 10yr5/4 none C.S. 0 f s ml 1/f n/a none .8 .7
B-3 I Houton Depth Dominant Color Mottles Structure Umlllnp Factory LoadlnyOPpa4. n.
In, Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Bounds Depth Trench Bad
1 0-7 10yr4/3 none l.s. 1/f/s ml 1/f G none .8
Elev = 2 7-11 '10yr5/4 none c.s. 0/f/s ml 1/f) n a none
97.2
13 _ 4 I Houton Depth Dominant Color Mottles 'Structure limit q Factor LoaaneOPOn4 . n.
In. Mun ell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Bounds Depth Trench Bad
1 0-10 1 r4 3 none s ?./m C none 4 1.3 -
Elev to 2 10=1 1 5/4 none I.S. /f/s ml 1 f G
98.1 n .8 .7
3 19-1 5 105/4 none s.
3~z' /f/s ml /f n/a none .8 .7
1 _ 5 Horton Depth Dominant Color Mottles Structure Llmlllnp Factor/ Loau~neGPO~t4. h.
In. Munsell u. St. Cont. Color Texture Gr. St. Sh. Consistence Roots Boundary Depth Trench Bad
1 0-12 1 r3/3 none s.l. /vf/sb mvfr 1/f C none .4 3
Elev
12-2 1 4/4 none 1-s- 0/f/s ml 1/f 7.50 G nonp -8 17
3 24-1 1 r5 4 none s. f s ml I /f n /A nnnp .8 -7
Additional Remarks: RECOMMENDED SYS Tit an
a e # 42 Soil series pNB
area of B-1-3-5 will be cut to app. el 5.01G `A
UP
m
other $Ite Features:
E
91.50 A-9 2- .(715 1246-62.nn
gna Date Signed Telephone No. CSt .
Sysfcm Elevation
Gary L. Steel 1554 200th. AVe New Richmond, wi. 54017
CST Name (Print) City Stale Zip
„r
Aon
(9,
1 ~
m~ t
S~•~z9
rN
V~
AS BUILT SANITARY SYSTEM REPORT
OWNER 7'd&jr / -5aA/ TOWNSHIP ~ST ~N2~s ~GJ.~
SECTION ~T 30 N-R-J:eW
ADDRESS U3 Si, . C40lx ST, W" ST. CROIX COUNTY, WISCONSIN
llwof0'V u)` 5 Y®/~
SUBDIVISION Pe/?CAO tAke- I?LOT_V LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N
~Y DI((j
k
SI `
3~-` 360
~lJd Gt0
r
`8 x yo r~~ S,
320'
Sa' t `L ` INDICATE NORTH ARROW
BENCHMARK: Elevation and description: /'t Ikem PJA~ EZ, 100, D
Alternate benchmark
SEPTIC TANK: Manuf acturer : U1 ELKS Liquid Cap. 1,06
Rings used:_D_Manhole cover elev: 95,,?Final grade elev: ~la
Tank inlet elev.: y~: 7s Tank outlet elev.: 93, 52
No. of feet from nearest road:Front_4, Side , Rear Ft..3D0
From nearest prop. line:Front , Side,, Rear Ft. L3,26
No. of feet from: Well , Building: .3°
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
~L
t
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact..: Pump Size
Elevation of inlet: Bottom ank elevation
Pump on elev.: Pump o elev.: Gallons/cycle•
Alarm: Man.: Switch Type: Location
Distance h nearest prop. line: Front-, Side-, Rear_Ft.
Di nce from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: -Length J! 0 Number of Lines:-,a__Area Built,_22.42
Exist. Grade Elev._? Proposed Final Grade Elev. 96
Fill depth to top of pipe: 30/1
No. feet from nearest prop. line:Front , Side_' ,X_, Rear Ft.Y/
No. feet from well: No. feet from building- 3/
HOLDING TANK
Manufacturer: Capacity..
No. of rings used: Elevation of botto
Elevation of inlet:
No. feet from near prop. line:Front , Side , Rear Ft.
No. feet om: Well , building , nearest road
arm Manufacturer:
INSPECTOR:
DATE : _ y-"'Z PLUMBER ON JOB : aC.-~7
LICENSE NUMBER: 3 -0~ ;
6/90:cj
LOCATIbN: ST. JOSEPH 29.30.19.301D,NW,SW,29,LOT #4, HIGHLAND VIEW
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 149283
Permit Holder's Name: ❑ City ❑ Village)] Town o : State Plan ID No.:
THOMPSON, LOREN ST.JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
Sprat 6w 030108330300
TANK INFORMATION ELEVATION DATA A9200127 z
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark, G
Dosing--1.
Aeration Bldg. Sewer -3.0611
Holding St/ W'nl et 10-57
TANK SETBACK INFORMATION St/kK Outlet ~p,yZ
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic ti7,6'k c NA Dt Bottom
Do NA HeaderJ.
Aeration NA Dist. Pipe 2.0 a cl
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manuf Demand o~ rCJ • ~,~b r
Model Number GPM T
TDH Lift Friction Syste Ft
Forcemain Length Dia. Dist. To Well
Fi
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~e DIME
LEACHING anufadurer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM
INFORMATION TypeOf fl, yQ > CHAMBER Model Nu .
System: OR UNIT
DISTRIBUTION SYSTEM
Header /AAao 4QId w Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing :JL SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over •4 ✓ Depth Over N xx Depth Of xx Seeded/ Sodded xx Mulched
No
Bed /Uajaah Center P?- 3b Bed / Tre~h Edges ~7- Topsoil ❑ Yes E] No [I Yes El
COMMENTS: (Include code discrepancies, persons present, etc.)
tz~j j", Z-V.'
Plan revision required? No
Use other side for additional information. 9
SBD-6710 (R 05191) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CouNTY
STATE SANIT PEgg~~AAIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 'L~ZS?j
8% x 11 inches in size. R] Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
LaRr.At T//a .Sol W t/4 Sal t/4,S T N,R j E(or W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
ZL3 57-, C
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
C ' -
11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
State Owned O VILLAGE T+ ~ 14
❑ Public X 1 or 2 Fam. Dwelling--# of bedrooms AR EL TAX NUMBER(b)
III. BUILDING USE: (If building type is public, check all that apply)
30 -/083 -3 eV
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Off ice/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 D9 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
140 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
r ® -7,246 4 75- 9/, 55' Feet 4 Feet
VII. TANK CAPACITY Site
in alIons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown o ttached plans.
Plumber's Name (Print): Plu s Signature: (No Stamps) /MPRS Business Phone Number:
Pk2ffAL1,/AJ- (216 F -66
Plumber's Address (Street, City, State, Zip Cod :
5_86 0,4LLi=X lilg4u 7-1?.
IX. 96UNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date ssue VWsuingApentSigaLune (No S
Approved El Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
i
SBD-6398 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
l
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
whenever pumper necessary, usually every 2 to 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:
i
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 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 appropr^ate 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, 'ocation of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains;/Hater 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, fricti;)n 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
1313 L",'iscon in Ac, 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The firior!ies € ol!ecIed through these surcharges are usod for monitoring ground',vater, groi,nd-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY ,
STATE SANIT4RY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ) L -l
8% x 11 inches in size.
WICheck if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
rh'f; ; tti '/4 '/4, S T , N, R E (or W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
1
CI , STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
~ A
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned O VILLAGE : ; Y,
❑ Public r7 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7E] Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 Seepage Trench 22 ❑ In-Ground 420 Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 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
71/) Feet Feet
VII. TANK CAPACITY . Site .
in allons Total # of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper
INFORMATION New istin Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holdin Tank El F1 I
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.
Plumber's Name (Print): Plum is Signature: (No Stamps) /MPRSW No l Business Phone Number:
)e, li
A
lumber's ' Address (Street, City, Stale, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
_y.
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerlyPib-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 rnav be renewed before the exPiratior elate, and at the time of rerevw it any new
criteria in the Wisconsin Administrative Code will be applicable.
3 All revis,-)rs tr this permit must be approved by the permit iss ping authority.
4. Changes .-,vrer.ship or plumber requires a Sanitary Per-if Transfer'Rerewai Fore (S '-P 6399) to be
submitted to the county prior to installation.
5 Onsite sewage systems must be properly maintained. The aptic tank(s) rr.:st t;- 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 adrn!nistrator 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. Provice 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 informat on 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 fcr- all
septic, pump/siphon and holding tanks for this system. Check experimental approval only f anks received
experimental product approval from DII.NR.
Vlll. Responsibility statement Installing plumber is to fill in name, license number with appropriate prefix (e.g.
PAP, etc.), address and phone number. Plumber must sign application fo-q.
IX. County/Department Use Only.
X. Ccunty/Department Use Only.
Complete plam• v-pecificatior;s not smalier than: arches m,sr:r be sub tittel; to l~p,r, county. The
Sf 1l ;?e A, p,!af~, Jr w3, .`P. pr with j _i(: }cation of
~Jjt '.ar , sr. . , . ,water service;
9 ~rc; rr!C anri (;+li.n mr nr eirhnr! r•Yc• .iictr F^.t~r... Lr+v ~+c ,r.~l ~{~q~.nt nn r. jrrtRa r~'~~•; ~r Ament s Stem
era <~~-e points;
,lc •;Url'1EH; (?It?v8f.,i ~r iffprfar:~frir~l,,fn loss: pump
+i!1~T1p5 and t;Qntr(
x-d pu"alt' 7))r s "'P c- t1BC'"tllJl.3 systern if
rcr,:,lufred by thr (Yil'ap', ii test ;iata or, a f; r§ • d r ) all s-; zing .lfotrr'a:; ii.
GROUNDWATER SURCHARGE
3.lion of
f uquiati;d prtnc;tice ; which cart effect groundwater.
ll'kl ~.}4t--Our,
{
thcrlsc li rc fiatgi ICi.` ,'.i~4!!t in-, g!
wafer c:orwa+r=irrr'ii(- invPstigations and establishment of stand,110s
SBD-6398 (R.11/88)
DILH a SANITARY PERMIT APPLICATION COUNTY
_DRa In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
%4 Y4,S TN,R E(o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Y
V
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) L:j CITY NEAREST ROAD
❑ State Owned VILLAGE
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms A hU
111. BUILDING USE: (If building type is public, check all that apply)
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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. L_I New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 420 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
. , < Feet r. Feet
VII. TANK CAPACITY Site
in alIons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New jExIsting Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tank or Holdin Tank l , -
Lift Pump Tank/Si hon Chamber F] 0 1 [1
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:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
❑ Approved ❑ owner Given Initial Surcharge Fee)
Adverse Determ n lion
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
I
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 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 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; close 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)
=:71-0M ~HR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CouNTY~
STATE SANITATITf PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ lL/~
8% x 11 inches in size. Check if re . on revioua 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
Y4 /4,S, T3c) ,N,R E(or Wo
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
sr o)x S~ A .
CITY, STATE i ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Hy N CUB . U/ P,512 c - d
CITY NEAREST ROAD
El I
II. TYPE OF BUILDING: Check one
( ) State Owned VILLAGE ~
4110 W:
PARCEL TAX NUMBER
❑ Public ;K1 or 2 Fam. Dwelling- # of bedrooms
ill. BUILDING USE: (If building type is public, check all that apply)
3 - O - 3 - o 0,0 ai
1 El 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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ►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 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
50 O 9AO 42-.5' , 95.0 Feet 98 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
Tanks ranks structed
Septic Tank or Holdin Tank Q00 EE ` -I'+- F1 r] Ej I El El
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.
Plumber's Name (Print): Plu 's Signature: (No Stamps /MPRSW No.: Business Phone Number:
Z op cM 0S
Plumber's Address (Street, City, State, Zip Code):
5-5 LLB 7-IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps)
Approved El Owner Given Initial J1110/q Surcharge Fee)
Determination O~ `off
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber
INSTRUCTIONS
1: A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the 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 maintaiiied. 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 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 that county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s'i, septic tank(s) or other treatment tanks; building sewers; wells; water ,-nains/Hater 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 lose; pump
performance curve; purnp model and pump manufacturer; D) cross section of the soil absorF tion system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
-
II
GROUNDWATER SURCHARGE
1983';'a sconsir; ".ct 410 inclUded they creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
Ii o rn "-fnies coi'..actt d throlrg}` these surcharges are.. E.a:+4-d 'or t-nonitoring groi.ind\k+.tter, grouno,
wager contamination investigations and establishment of standards.
SBD-6398 (8.11/88)
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 Lyek o s
pQ'.r5 Cu ~t' S Gv
Location of property_&:a/ 1/4 S' V 1/4, Section ~g , T 30N-R/ 9 W
Township Sy, C'7'6 2,2b
Mailing address ~y0t k Sr ,
C! k wIT 5-yo
f ~j
Address of site S~ orF~b w~
Subdivision name /Ier^l t q~p P Lot no.
Other homes on property? yes X No
Previous owner of property C~-o ;41 i"cr _ r t p No a er /~g It Total size of parcel 3, 3y' a C'
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes 4_N0
Volume, F26 and Page Number o~'L?o 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. 7 g / , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No.
Signature of appli ant Co-applicant
3-20 C/
Date of Signature Date of Signature
DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
ii STATE BAR OF I CRNSIN FORM 2-1982
1467591 VbL o
_ _ _ .1 REGISTER'S OFFICE
Perch Lake Ridge, a partnership consisting i ST. CROM CO., WI
-of --J' Anr1"'Persi-co-3 ---Roger-- Reell-n---an-d-$ru-ce---------- Recd for Record
_ Peter~o-ri------------
- - MAR 2 1991,
- - - - - - at
-
conve -s and warrants to Oren -..Tho.. -.-.....o11 sin le :25 Mt
person
V l.~hra
Register of Deeds I
-
RETURN TO
I I.
the following described real estate in St • Cr01X County,
State of Wisconsin:
Part of SWk of SW 3-4 and Part of NW I-4 of SW -4 of Tax Parcel No
Section 29, Township 30 North, Range 19 West,
St. Croix Count Wisconsin described as follows:
Lot 4 of Certified Survey Map filed March 21, 1989 !
in Vol. "7", Page 2081, Doc. No. 446220.
TOGETHER WITH AND SUBJECT TO a 66 foot wide Private Road as
described in Vol. "816Page 362.
Ii
'IRANa
$y.~o !
is not
This homestead property.
(is) (is not)
Exception to warranties: easements, restrictions and rights-of-way of record,
if any.
March
Dated this - day of 19.9
I!
?
-~~~!!e7J.-1~~2e -
•----------------•--(SEAL) (SEAL)
-
Roger Rueli
- --JoAnn...... s .co--------------_------ iI
-----•--•(SEAL) ------(SEAL)
Bruce Peterson
AUTHENTICATION ACKNOWLEDGMENT I~
I
Signature(s) STATE OF WISCONSIN
I
ss
authenticated this day of 19 Personally came before me this day of
March
- .named
I -----------•---------------•------19-•-1---the above named
Roger Ruelin' Bruce Peterson,
TITLE: MEMBER STATE BAR OF WISCONSIN JoAnn Pers_ i
(If not, 706............................
authorized ed by § 706.06, Wis. Stats.)
to me known'to b (~ys D ho executed t
he
fo a oing instr do t same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina• 0 land Lundeen _ I~
Alice J V.-IC
Attorney at Law
~I
Notary Public .q O . .......County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is state expiration
Me not necessary.)
date: Uly-••••---•-•---•--•••...........-•••., 199.3--••)
I I
of persona signing in any capacity should be typed or printed below their signatures.
tFARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Cu. Inc.
FORM No. 2- 1982 Al Iavidkec. Wib.
R
LULAIEU IN PART OF THE SH4 OF THE Silk AND THE NH OF THE SW 4, ALL IN SECTION 29, T30N, R1911,
TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN.
OWNERS
Roger Ruelin JoAnn Persico Bruce Peterson
505 Galahad Rd. 131-A Willow La. Rt. 3 Box 56
North Hudson, Hi. Hudson, Hi. Hudson Hi.
H~ CORNER ! .54016 54016
SECTION 29 54016 Ll~
13011, R19H .7 ~.t - S~•~,~. ,7^i
.l•'. ~~?.ETd
LEGEND'007
j
FOUND, ST. CROIX COUNTY SECTION CORNER MONUMENT. huDSOV, f
c SET, 1" x 24" IRON PIPE WEIGHING 1.68 POUNDS PER LINEAR FOOfi,7 I\4z,Ce,~M~+••''' -LrJ ,'yLk'
1 J~ wCjY
O CURVE IDENTIFICATION NUMBER
S~~
unplatted lands owned by platter
S89000'22"W 770.00' o
U,
0 C) 307.31' 80.0' =
382.69'
O N
690.00' `
~ U
h ~ ~ .-la
L4J N
167,368 sq. ft. (3.84 ac.)INCLUDING R/W o / w i
157,119 sq. ft. ~
EXCLUDING A/W o LLJ L,
(3.61 ac.) 4 0 0
N 9000'22"E 6' % ✓ Cn CD
187.02' 158.871
545.89' . 33.07' - H ~
3 ~ m=m
146,294 s q. t.
;`A o q' INCLUDING R/H
(3.36 ac.) S53013101"E, 100.00'
135,840 sq.,ft. 3 EXCLUDING R/H 1153°13'011% 100.00'
o; (3.12 ac.)
N89o00' 2 "E 1 , 84.55'
0 658,
306.89' 300.00' 15.45'~~J 51.29'
o- 606.89
C +d'
south_ line of the;` o a,
o NH} of the SH} \At'~,, 167,830 sq. ft. (3.85 ac.)INCLUDING R [W
y\
e P `Q 158,667 sq. ft. (3.64 ac.)EXCLUOING R/W
~R c O
%Aj
089000'22"E 665.77' a\ ' o
0 631.13'
%A, 34.641
a
J o`
164,472 sq. ft. (3.79 ac.)INCLUDING A/W r\o•',,,\
i 155,811 sq. ft. (3.58 ac.)EXCLUDING R/H
785.96' 165.36' 615.36' 450,00, \ 34.641
H89000 '22"E 650.00' \
\
unplatted-lands-owned -by-platter
z G~ 66 FOOT WIDE PRIVATE ROAD EASEMENT
o ~ •
°SCALE IN FEET
260 100 0 200 /
SW CORNER /
~0
. ~ , Ion
Op dp
v o
r. ~
Co
r,
r
v 7 a
Q
` 71' 6 S ~Io' ~r ~
i
~ N
O
N co
O (M
O ca
C" •
co
N
cn
2~~
• to
• y
ST C- 105 r
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
9
H
OWNER/BUYER Lover R, ~Oal c*l!
ROUTE/BOX NUMBER 7-_)/ Fire Number
CITY/STATE Y d SOk I X'.r " ZIP S~o~6
Pars S'w Of sw ac
PROPERTY LOCATIK. IVUI_14D~ S6v k, Section, T ~ON, R~W,
Town of 5-f, 1-o 3,ea St. Croix County,
SubdivisionPef(4 14ke Lot number- .
Improper use and maintenance of your septic system could result in
. Proper maintenance con-
its premature failure to handle wastes
sists 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 treat-
ment 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 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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), 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 expiration. H
0
F:
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- •v
ment 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.
SIGNED ~
4
DATE L~
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'IN~+DUSTRY, DIVISION
LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS HIP/h4jf*96L?M TY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
NW 14Swl/4 29 /T30 N/R19)&(or) W St. Joseph n/a n/a n/a
COUNTY: (S BUYER'S NAME: MAILING ADDRESS:
St. Croix Loren Thompson 1723 St. Croix St.N., Hudosn.Wi. 54016
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER ATION TESTS:
Residence 3 n/a ]NNew ❑Replace 2-11-92 3-18-92
RATING: S= Site suitable for system U= Site unsuitable for system 1
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®S ❑U ®S ❑U ❑U ❑ S ❑~U 1:1 S ®U conventional
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS pane 42 R1B
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH I ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 9.25 96.25 none >9.25 .92bn.s.1.. 1.50bn.l.s., 6.83bn.c.s.
B- 2 9.67 99.25 none >9.67 .75bl.l.s., .92bn.l.s., 8.00bn.c.s.
B- 3 9.58 97.25 none >9.58 .58bn.l.s., 9.00bn.c.s.
B- 4 9.58 98.15 none >9.58 .83bn.s.1., .75bn.l.s., 8.00bn.c.s.
B_ 5 9.00 97.50 none >9.00 1.00bn.s.l., 1.00 bn.l.s., 7.00bn.c.s.
B-
deciaml' PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER XXNNM AFTERSWELLING INTERVAL-MIN- PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ 1 4.75 none 3 6 6 6 <3
P_ 2 6.00 none 3 6 6 6 <3
P_ 3 5.75 none 3 6 6 6 <3
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.
SYSTEM ELEVATION 91.50
E~
7- i'lob A 0,
f
- I - - N
E
I
,
I~ ~ a
,
P r ! 3
i
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures 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 WERE COMPLETED ON:
Gary L. Steel 3-18-92
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. AVe., New Richmond wi. 54017 22
CST S GN E:
r
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
i
n, s
INSTRUCTIONS FOR COMPLETING FORM 115 - SRI - 6395
To be. a complete arid accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate wh tr this is a residence or commercial project;
3. MAXIMUM number of bedrooms or c I use planned;
4, Is this a new or, replacement system;
5. Comp!Pte the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHE R SYF''r-MS ARE RULED OUT BASED ON SOIL CONDITIONS;
0. PL itions shown here for writing profile descriptions and <r,ni the plot plan;
7. MAK' LE IBLI diagram accurately locating your test locations. Drawing to lie is preferred. A
heet may be, used if d---d;
B, your benchmark a A rl elevation reference point are clearly shown, and are permanent;
9. C:r 13: appropriate boxes 'o dates, names, addresses, flood plain data, percolation test exemp-
tion, rapropriate;
10. If the information (such as flog yin, elevation) does apply, place N.R. in the appropriate box;
11. Sign the form and place your crrr --idress and your ~:-t =tion number;
12, Make legible copies and distr= y required. ALL SOP TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Sion€k (over 10") BR - Bedrock
cola - Cobble (3 - 10") SS - Sandstone
gr - Gravel (under 3") LS - Limestone
~s - Safi ' HGhV - High Groundwater
c~ _ " d P_--- _ Rate
med - .1 Sand
Is : Sand E g
Is Loarny Sand > - G ,ater Than
'sl - Sandy Loam < Less Than
~l - Loarn Bn Brown
.sii Silt Loam BI - Black
si Silt Gy Gray
'cl - C'sy Loam y 'y low
scl - ?y Clay Loam R -
sicl - f ty Clay Loam r - 'pies
sc idy Clay
sic - Silty Clay - v, fine, faint
x'c Clay cc - common, coarse
of Peat friar Many, medium
m - Muck d - distinct
p - prominent
HWL - High water level,
Six general soil textures surface water
for hquid waste disposal BM - Bench Mark
VRP Vertical Reference Point
TO THE GINNER:
This test report is the st step in securing a rani` y permit. The county or the Department may request
ve `a--r of this sr;, `-i prior to issuance, A complete set of plans for the private
and a k ,icr I -dust itted to the appropriate local authority in order to
o°~.tain a permit. The san-ary permit mist be obtain and posted prior to the start of any construction.
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