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HomeMy WebLinkAbout032-1041-30-110 -O o 1 llz- y o It 3 o O o is a) N ~ I © I ~ I 0 M Q X ~ L y U i` N w O Y C Z co C W U. O O) R3 O Q ~ M a) 3~ z U) _ v o z m a~i F- U) a m I E t~ d c m Z ~ ~ N 0 CL 0 Z U) N ' N - O AV ~ U U C w O` O Z F Z Z O N c 1 E E N W ~ Y O - IL C..`0 b O W N C o Lo G G a a c o z~> ° v H H F a ~ I O O O 0 i ~ a a a a a~ i N N -j E 0) a) t% U rn UO) r a) N o 0 E N O O O °r d CIO L U) a) rya N w Q ~i C rn 3 O o o c w c U 3 N o c c LO co O O N E O N OR N UCf p L CO O O a CL CL N C N E E N 00 co a) 0 C ~ N cu F F _ ao)) CO O O n E E v cO ~ V 3 a L a ~~ww CL d U d « d E ` c A U a 2 0 U) o AS BUILT SANITARY SYSTEM REPORT i' OWNER <11AJ ),9 TOWNSHIP SECTION T 2. N-R_L9_W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT1~ LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tfaUs~ _I • ys' d s' , s //o i INDICATE NORTH ARROW BENCHMARK: Elevation and description: ~ Alternate benchmark SEPTIC TANK: Manufacturer:!/mss Liquid Cap. Rings used:,,;2-Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front , Side, Rear Ft.,-~~ No. of feet from: Well Building: 7* (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE I i r 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: Seepage Pit: Width: ,S Length Number of Lines . 2S7- •-c,?,_Area Built Exist. Grade Elev. ~?'yg~Proposed Final Grade Elev. Awl Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side' , Rear_Ft.,,~a No. feet from well:-4~_No. feet from building__ ,2i; 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 : h` < 2, 2 PLUMBER ON JOB:- LICENSE NUMBER: 6/90:cj ~I LOCATION: SOMERSET 14.31.19.202C-10,SW,SW,14,60TH ST. a Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: SaLaborfety and and'Bumauildinngs Relations Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149278 Permit Holder's Name: ❑ City ❑ Village][] Town of: State Plan ID No.: ROZELL, LINDA SOMERSET CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 032104130110 TANK INFORMATION ELEVATION DATA A9200 e TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ~j U. (PS , Aeration Bldg. Sewer Holding St/ Inlet TANK SETBACK INFORMATION St/ Outlet ' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade M Demand 7P ° S 7- ,v,- ~ / Model Number GPM - 2,51 S 99 TDH Lift Friction System H Ft oss Fi Forcemain Length Dia. Dist. Towels SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS a DIMEN I N SYSTEM TO P/L BLDG FWELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O C ALL , CHAMBER Model Number: System: LIM,4 &S o OR UNIT DISTRIBUTION SYSTEM Header p Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length J4 Dia. Length/4 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench Edges Z S/~ rr Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons resent, etc.) a d o uJ err c /2,aZ A06 /y!82 /4/, 09' 414 Plan revision required? ❑ Yes []-9-0-- Use other side for,additional information. SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' I SANITARY PERMIT APPLICATION 7DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ N 8% x 11 inches in size. Check If revis on to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUPBER ' 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. I PROPERTY OWNER PROPERTY LOCATION N R S (or) /a+ 1/4, T PROP RTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑ State Owneda ❑ VI =TY LLLAGE A - NEAREST ROAD PA TOWN OF: ❑ Public 1 or 2 Fam. Dwelling~# of bedrooms -PARCEL AX M 111. BUILDING USE: (If building type is public, check all that apply) © /6 V/ _ q~, 1 ❑ Apt/Condo dam- V 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 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. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 0 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Mi /nch) r/ y~s/ ELEVATIPN 46-if, 7SG 7 5"G f ~ 9s, 41-Feet --Feet VII. TANK CAPACITY LCon- in allons Total # of Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Steel glass Plastic App Tanks Tanks ed Se tic Tank or Holdin Tank It. C F1 n Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati of the onsite sewage sy em shown on the attached plans. Plumber's Name (Print)` Plumber' Si atur : (No m r / MP/MPRSW No.: Business Phone Number: Z Plumber' dre (Street, City, State, Zip Code): 1 IX. CO TY/DEPARTMENT USE ONLY ❑ Disapproved SqpItary Permit Fee (Includes Groundwater ate issue kwsuluQ ent ok re No S ps) proved [__1 Owner Given Initial Surcharge Fee) /&19~ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-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, sanitar;'i ermit may be renewed before the expiration date, and at the time of renewal any, new criteria in the Wisconsin Administrative Code will be applicable. 1 All revisions to this permit roust be approved by the permit issuing authority. 4. Chanties in cwnership or plumber requires a Sanitary Permit Transfer/Renewal Form (13611 , 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The sept c tank(s) mu,•t bE! purl ped by a licensed purnpor 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 tk:nks 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'/z 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 surchargE~S (fees) for a number of regulated practices which can effect groundwater. The monies collected thiough these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------7-------------------------------------------------- Owner of property L' n d 0. k 0'2-Z ) S Location of propertyj(,,J 1/450 1/4, Section , T -3 _N-R,ia_W Township ,jam r z~- Mailing address L~0 Address of site;/ /J 'Z I -/r Subdivision name Lot no. e Other homes on property? yes_ No Previous owner of propertyy++ r MOL i r) Total size of parcel ~-1 0--1 , C -e-s Date parcel was created b(D q a Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number 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. , 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 a licant Co-applicant Date of Signature Date of Signature i j DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA 4804C2 STATE BAR OF W11~ SIN' F -1982 aJ VOL llvv~~' f'QuI ~JO Edward E. Germain and Ann Marie Germain, REGISTER'S OFFICE Yiiisbarid and wife as joint --te-narits---I----------- ST. CROIX CO., WI - Reed for Record . - - fy1AR 3 1992 - - conveys and warrants to - °Z---------- at 8:/5Q0 A. N1 f . - V - Register of Deeds - j RETURN TO I~ the following described real estate in Croix County, - State of Wisconsin: Tax Parcel No_ ii Part of SW4 of SW4 of Section 14, Township 31 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lot 5 of Certified Survey Map filed March 9, 1992 in Vol. 11911 , Page 2454, Doc. No. 480266. i I ii This - 18 - - - not homestead - Property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. I 44,~ Dated this day of - March - - - - , 19._92.. p~ QJ C~ , /t! X-_____-------(SEAL) Kl1 (SEAL) Edwar.d._E,.__.erm~ n_... --------Mar... - erman.- (SEAL) - - - - --(SEAL) - - - - - - - AUTHENTICATION ACKNOWLEDGMENT Signature(s) EdWa-r'd_-E_,_--Germaln,___-.--__. STATE OF WISCONSIN i ss. Ann._Mari e...Germain ---------County. authenticated this l~_..-day of...... areh-------- 19.92_ Personally came before me this -.__.._______-day of 19-------- the above named - - Kristina__-Ogland___Lundeen TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kriatina__Dgland...Lundeen ii Attorney at Law Notary Public ---------------------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date- 19--------- *Names of persons signing in any capacity should be typed or printed below their signatures. ~nr .I ♦-+,i ~4 r.. I.,, _ CERTIFIED SURVEY MAP LOCATED IN THE SW1/4 OF THE SW1/4 OF SECTION 14, T31N, R19W, TOWN OF SOMERSET, ST. CROIX COUNTY, WISCONSIN W1/4 CORNER LOT 1 CSM 4 SECTION 14 VOL. _1_PAGE 236 T31N, R19W DOC._#332995_ off o - 0 i . ^ I U r-4 z `n I W3rn 00 I x -4 I S87°48'40"E 438' w -w pq 33 405' w H o 0 ~ o 66' cnI rziw~ ~H w LOT 5 zl W a All 0 177,237 S.F., 4.07 AC. -4I oa H zll Including right-of-way al H -P, - - 3 H al 163,883 S.F., 3.76 AC. - w Excluding right-of-way ~ oN w~ H U) AI D 0 0 0 ~ HI HII w w SCALE IN FEET 0 0 F+I F N N al ~I ~er^ a+I of 120' 240' e' , wl ~M C o zl C14 C14 . zl Iz o 44 z z AI A I I G A,V 33' 405' N87°48' 40"W 438' i JAN O a 199? i 3 T POINT OF BEGINNING j ST. ("M, Ix ~:::)kJ'lTy WI C0N4P1t'rvNENSIV'z.. 0Af2k:a PykNdaiUr:~ o LOT 4 CSM j AN) h,.uTN(~ t:tN~}nn~IlFi C'4 VOL. 3 PAGE 746 DOC. #353786 rn C 14 SW CORNER SECTION 14, T31N, R19W LEGEND ® COUNTY SECTION CORNER MONUMENT, FOUND. ® EXISTING 1" IRON PIPE. - EXISTING FENCE LINE OWNER AND SUBDIVIDER EDWARD GERMAIN 2102 HWY 35 SOMERSET, WISCONSIN 54025 This instrument drafted by Michael E. Burke. DESCRIPTION A parcel of land located in the SW1/4 of the SW1/4 of Section 14, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin, described as follows: Commencing at the SW corner of said Section 14; thence N2°11'20"E (Assumed Bearing) 691.00' along the West line of said SW1/4 and the centerline of 60th Street to the point of beginning; thence N2°11'20"E 404.65' along said West line of the SW1/4 and said centerline of 60th Street; thence S87°48'40"E 438.00'; thence S2111120"W 404.65; thence N87°48'40"W 438.00' to the point of beginning. SUBJECT to an easement for existing town road right-of-way on the West 33' of said parcel. Parcel contains 4.07 Acres, being 177,237 Square Feet, more or less, including town road right-of-way and 3.76 Acres, being 163,883 Square Feet, more or less, excluding town road right-of-way. I certify that I have made such survey, land division and Certified Survey Map by the direction of the owner of said land, that such map is a correct representation of all the exterior boundaries of the land surveyed and the subdivision thereof made, that I have fully complied with the provi- sions of Chapter 236 of the Wisconsin Statutes and the Subdivision Regu- lations of the Town of Somerset and St. Croix County in surveying, dividing and mapping the same. Date: January 23, 1991. Revised: December 31, 1991. Francis H. Ogden S-882-Job No.91-190 Ogden Engineering Co. 113 W. Walnut Street River Falls, Wisconsin 54022 ~ OWNER AND SUBDIVIDER ' FRANCIS H. OGDEN EDWARD GERMAIN fil L% _ 2101 HWY 35 S FFAL V" Q` SOMERSET, WISCONSIN 54025 General Notice: Each parcel shown on this map (plat) is subject to State and County regulations (i.e. wetlands, minimum lot size, access to parcel, etc.) Before purchasing or developing any parcel contact the St. Croix County Zoning Office for advice. SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1 G` R D Z e ADDRESS: 0-E ) lQrw 1 Sr`I~ FIRE NO: LOCATION:- 1/4, X1/4, SEC._ -T_ZLN-R_J~2_W,,. TOWN OF: ST. CROIX COUNTY X 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: ql"A~. " DATE : St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS `INDUSTRY, CC DIVISION LAJBOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MIRY: r OT NO.:BLK. NO.: SUBDIVISION NAME: SW 14 T31 N Rl9~(or) w Somerset 5 n/a n/a . COUNTY: OWNER'S/BUYER'S NAME. MAILING ADDRESS. St. Croix Ed Germain Box 120S, Somerset, Wi. 54025 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILED S R PTIONS: PERCCF ATION TESTS: Residence 3 n/a )ENew ❑ Replace 9-21-E89 n a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSU SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) H4 I ®S ❑ U CAS U] S ❑ URE: S S EA# step down trench If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: class 2 ( Floodplain, indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 10 CoC2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH I LEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 7.34 95.73 none >7.34 1.17bl.1. 1.50bn.sil. 4.67bn. m.s. B-2 7.00 98.84 none >7.00 .50bl.1. 1.00bn.sil. 1.50bn.l.s. 4.00bn.m.s. B 3 6.84 97.15 none >6.84 .92bl.1. 2.00bn.sil. .92bn.l.s. 3.00bn.m.s. 13- 4 6.58 98.84 none >6.58 .83bl.1. .83bn.s.sil. 1.42bn.l.s. 3.50bn.m.s. B-5 6.91 95.14 none >6.91 .83bl.1. 1.33bn.sil. 1.08bn.l.s. 3.67bn.m.s. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P PER INCH P_ P P_ S e eS gn rate P- I P- t P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicatk scale or distan65'Oncribe wha a the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all bbfln d{ n the diio and percent of land slope. upper trench=95.34 SYSTEM ELEVATION lower trench=93.65 I~ S I I F 5".5 UJI t j I N f i r i ( I lot - _ _ 4,31 i 2 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 9-21-89 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 988 N. shore Dr., New Richmond, Wi. 54017 2298 715-,246-6200 CST SIGN RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - ` M I a INSTRUCTIONS FOR COMPLETING FORM 115 - 6395 To be a co r ai = accurate soil test, Your report .elude: 1 . Comp; _ on; 2. The use =rly indicat Cher this is a silence or commercial project; 3, MAX` omsor -nercial u -ned; 4. Is tl-.!,> i; 5. Comp! !te tf suit ig boxes, SITE IS SUIT BLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEM I FLED Ot, BASED ON SOIL CONDITION 6. PLEASE use the a',f, shown - for writing protile descril'' completing the plot plan; 7, MAKE A LEGIBLE i, accura`.acing your test location:. I tg to scale is p-nf°,-~?d, A sepaia' 'met rnal desired; 8. Mak )d verti( ion reference poin t; . i ; xes as tc names, addresses, colation e>~emp- s flood pl-i , 11) does riot the appr"opr"iate box; 1 1. our curter _ yoruV ni 11ber; and distribute - I. ALL SOIL - i "S MUST BE FILED WITH THE AUTHORITY INITHIN 30 DAY C) 7MPLETIC}N. VIATIO CERTIFI TESTERS T v /snbols st - wer 10` EBedrock - C t3 - 10?') _ andstone (under 3") nestone C....... r1 9 P I > Thin Bn B1 G y Y L Ft Lc mot - Clay C, 7,Y Y tin Six i, textures uG~: .u for ~ disposal BM Bench Mark VRP - Vertical Reference Point r TO THE OWNER: Th= -;i1 r-st report is the first in securing a san tary permit. The --u-, -,the Department may request tion of this soil fie .or to permit issuance. A set of plans fo, the private 'm and a l - "t e s 'smitted the appropriate local autl"~ority in order to a - a! 1 "ior to the start of any construction, -C/Gec J. N• ~.:ad,J/ y v, f %w