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AS BUILT SANITARY SYSTEM REPORT
OWNER ~.CJWiUERAICS TOWNSHIP 77:r,?~Y
SECTION _T-2-~E_N-R -/9 W
ADDRESS 6,71 /0 Sr Al ST. CROIX COUNTY, WISCONSIN
~fuDSOJ GJr S~/~/G
SUBDIVISION ~OUT~~~PK LOT-2.1-LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
SouTp K 40.
JJoQTH J 0f~ r/ /NE
i
i .
G✓~c~
0:S -'3
1'poio5tp ~('iVBwAy
P~/~, s c ,r 4o r VEN rs
`11eAJE C~G~. /Ob. oo y3~~~ y - - se,, 4o Q✓C stwf~ /NE
2so ~ 1 EPr~c -rAo K
` GJiTNC~s7?ir<aN
A" kp5#0
w, r/l Aaen rE AN L
~a j L S 0'Q 3s r-FAH .vr
4\ Q«uP'd ox w , i1AX
SOu?N [TH 4Gtt,.tkc
P,paoEr piSTPC~guTrD.J Sv 4ordTrucNes
L~.iNE
INDICATE NORTH ARROW
JVo Sc.1L6
BENCHMARK: Elevation and description: fP of Aowge rrp~s7-xc S c~~orLor~v~
Alternate benchmark VA
SEPTIC TANK: Manufacturer: L✓.,Fs---,P Liquid Cap. 1a5-Q6~ -
Rings ,used:2__:~ Manhole cover elev://o- Final grade elev:
Tank inlet elev.:104 .3T' Tank outlet elev.: /ad
No. of feet from nearest road:Front , Side Rear Ft.
From nearest prop. line:Front , Side , Rear t'Ft. 413
No. of feet from: Well_ ~)Ir, , Building: as
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
R
r
t
. ,fit •
PUMP CHMMER
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
E{t V. A 10:x. 3 ,
Bed: Trench:a_
Seepage Pit:
Width: •~Len th fig'
g Number of Lines:_ / __.Area Built-)!~tos4.F~
in<,. 2' A ins r'
Exist. Grade Elev.X Proposed Final Grade Elev.B ins o'
Fill depth to top of pipe: 1
-
No. feet from nearest prop. line:Front ✓
Side'•~ Rear Ft.!V,
_
No. feet-from well : i>D' No. feet from building 413"
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: a PLUMBER ON JOB: S
LICENSE NUMBER: WPS- 33 9s
6/90:cj
LOCATION: TROY 7.28.19.1049,SE,SE,7,SOUTH FORK RD., LOT #12
• Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Irab~or and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIXi
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 149320
Permit Holder's Name: ❑ City ❑ Village?(] Town of: State Plan ID No.:
GERNES JOHN TROY
T BM Elev.: Insp. BM Elev.: BM Description: r arcel Tax No.:
CS
040121770000
TANK INFORMATION ELEVATION DATA A92001656,aS- z
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
D
Aeration Bldg. Sewer j167 7'1
(o/
Holding St / Inlet -206,
TANK SETBACK INFORMATION St/ Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
D NA Header /-Men.
5'sv93
Aeration NA Dist. Pipe
Holding Bot. System D'70o
PUMP/ SIPHON INFORMATION Final Grade
u acturer Demand °1 ° ff 3 Sg'
Model Number GPM
TDH Lift Friction Syste TDH Ft
Head
Forcemain Length Dia. Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT is Inside Dia. Liquid Depth
LEACHING Man turer:
DIMENSIONS 1 vo EN I N 07/ 1 SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type Of n , , CHAMBER Mode Number:
System: e& V ~J V3 )16n 414 OR UNIT
DISTRIBUTION SYSTEM
HeadertMaff444 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length -/2-1 Dia. `t Length 3) Dia Spacing ---!2/
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 Topsoil El Yes No E] Yes No
COMMENTS: (Include cod discrepancies, persons present, etc.)
r~ 7l
7 -7
Plan revision required? ❑ Yes ❑O
Use other side for additional information. Q-
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
IL HR SANITARY PERMIT APPLICATION COUNTY
.70 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 ❑ LfQ/~
8% X 11 inches in size. Chk,~i((ree is p ev s; 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
o,qA/ ,,CS S ~ T N, R E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
5a / ,g ~ T A/. AJA
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
0501J w• Sy0/6 P/ IM-! 9 SO,rr-r/ "ao'e.
Il. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State Owned VILLAGE : ~O sv
El Public 1 or 2 Fam. Dwelling-## of bedrooms PARCEL AX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) 0 ~a _ _ D D
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
40 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. aNew 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) A 102. Sa' /4 5fV-T4QN
00 9 ` 0:51 , $ VQ 54. fr, 3 6 / OR- / O 'Feet 10 S, o0 Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holding Tank IIW50 ! SO !,c)i~5 E
Lift Pump Tank/Si hon Chamber F1 I El 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' ign ure: (N Sta pMP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
12 -1 S e; `W . b~ t, So ) Z-J, S_Vv/
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanita ermit Fee (Includes Groundwater rate Issued Issw Agent Signature (No Stamps)
O a Surcharge Fee) -
Approved ❑ Owner Given Initial
Adverse Determinate n
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS "
1. A sanitary permit is valid for two (2) years.
2. 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 (S8D 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, purnp/siphon and holding tanks for this systeem. 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 +arik(s), septic tank(s) or other treatment tanks; building sewers; .tells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil ahsorption systems; repiacement system
areas, and the location of the building served; B) horizontal and ve-tica? elevation reference points;
C) complete specifications for pumps and controls; (lose volume; elevation, differences, friction loss; pump
performance curve, purnp 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 Wlscons n Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
Tare rnonies collected through these: surcharges are uses for roanitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
STC-loo
This application form is to be completed in full and signed by
the oc;m er(s) of the property being developed. Any inadequacies
will only result in delays of the
permit issuance.
development be intended for resale by owner/contr ctor,l(spec
douse), 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=l/4_1/4, Section
~ TN-R,,,IW
Township
Mailing address S- 4h
Address of site
Subdivision name- a~ fork QVITio n
Lot no. )2
other homes on property? yes--4_No
Previous owner of property pn~, ~+'~er 5
--4- T n e
Total size of parcel 2. 4 QG
Date parcel was created `
Are all corners and lot lines identifiable?
--,L<-Yes No
Is this property being developed for (spec house)? yes _.X_No
Volume- and Page Number as recorded.with the Register
of Deeds .
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARIUVITY DEED which includes a DOCUMENT NUIMER VOLUHE AND PAGE
NUMBER & THE SELL OF THE REGISTtal 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
Deed, as Document No.
own the proposed site for the sewage , and disposal t sI (we
ystem) orrI(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.
C. ~JZ~te2
4in at ure of ap~licant
Co-applicant
~ 3a Q 2 •
Date f Signature
Date of S gnature
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2 -1982 !
482819
vo►_ 948wE 468 REGISTER'S OFFICE
ST. CROIX CO., WI
ZAPPA-BROTHERS EXCAVATING, INC., a Wisconsin ti RBCid for R@COfd
.__--corporation. Grantor - - -
- MAY o 11992
- - Ct 11: 55 A. M
conveys and warrants to GERNES-- and. SHARON F, GERNES,
h-usb-and-. aud..wife - as - survivorship marital property, . , .
- -
- - Register of Deeds
-
- - - -
RETURN TO
l
I~' - - _ _
the i
the following described real estate in St..-_.CI•D1X-------------------- County,
- -
State of Wisconsin:
Tax Parcel No: 040-1217-70
i
Lot 12 of South Fork Addition to the Town of Troy, St. Croix County, Wisconsin.
I
it
~y7~xt
F i1 A
I
EWE'
TOGETHER WITH AND SUBJECT TO reservations, restrictions, easements
and rights-of-way, if any. j'
!
I
This is riot homestead property.
(is) (is not)
Exception to warranties:
Dated this ---------A th--------------------- day of April - 19-92
ZAPPA BROTHERS EXCAVATING, INC.
---(SEAL) --.---l~?tJTQ6r!T------- (SEAL) !I
I!
- - - - * - BY; Gar-y _ZaP.pa,_. Pze_giden.t !
i
-.-_.-(SEAL)
-----------------------------------------------------------------.(SEAL) - -
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
ss.
St. Croix
County.
authenticated this ..day of___________________________ 19______ Personally came before me this 30th---- day of
_April 19__92__ the above named
* Gary Zappa, President
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 a acl~wled the same.
THIS INSTRUMENT WAS DRAFTED BY
Attorney Barry C. Lundeen
MUbCE;--PORTER--Z--LUNDEE'1T;--S-.-C---------------- * Richard- -F.--Prok sh
1JQ__Second--Street: Hudsont WI 54016 St. Croix
Notary Public . ---------------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) January 17
date- 19_. 3...)
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co , Inc.
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Jch n 5hp,+rp h
ADDRESS : 52,1 ( Olk 10, FIRE NO :
i
LOCATION: fl:- 1/4, 1/4, SEC. TAN-R W,
TOWN OF: /jo U ST. CROIX COUNTY
SUBDIVISION: Soc~ ~'~ar K Ro~~ ran LOT NO. ~Z
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: C
I
DATE:
YZIO 2-
i
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
INDEPA-ATMENT DUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
' .TRY', DIVISION
INDUS
7969
LABOR AND PERCOLATION TESTS (115) P.O. BOX
3707
HUMAN RELATIONS MADISON, W1 53707
(ILHR 83.09(1) & Chapter 145)
LOCF-A,/ SE~O~TZeN~R19 E (or) W TOWNSH eO i2.4i~1~Y: LOT NO.: BLK. NO.: SUBDIVISION NAME:
1~ 'I 1/Z `500TNPo2k
C NTY: OWNER'S BUYER'S NAME: MA LING ADDRESS:
C etM
J GEeNfs
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFI DE RIPTIONS: PER O ATI E TS:
Residence XNew ❑Replace L~ Z / 4 ~Q
50 l~.s k - ~o c S - + ~LLbT
RATING: S= Site suitable for system U= Site unsuitable for system ' &)KV-_WAk,&-r
CONVENTIONAL: MOU S EA IN-GRO P❑~RE:SYSTEM-IaILLH~INGTANK:RECQMMv~DE~NAML(opl)
XIS 1 9
If Percolation Tests are NOT required DESIGN RATE: ( I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: IL 4V5 Floodplain, indicate Floodplain elevation: Q
C T PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH lid, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- b f /I.O~s //'BC.SLTS /Z"~BaNSC 7o"$aNrhS~Ge ~~$~eN
B- 1,47- mj-z NOW6 > 114Z- 68°6e.~, M1I(A& 39*Ae vA5
B- 3 Q~S / .IZ 6 > 9.15 _'K"BLsc.TS z4"6R,a1hs /3K$~NMS72''$apj MS
B- 4 ~3 /~3, IIZ N > 943 9 I-SCTS 7 "8R1„SL &*z1,9N5C4it A6''szv Aq S
B- S q 97 /04 . o > 9.9Z. /~"$cscTS "$a•~SL 7e'$aN MSSi Ge ZY''~ ~tw~ WI ~
B-
UC.VT PERCOLATION TESTS
TEST D PT WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERS ELLING INTERVAL-MIN. PERIOD1 PERIOD2 PER PE INCH
P- I a N60 L- 167.10 3 > > Z > <
P- 7. d ►J 116.)6 3 > >2 > <3
P_ z. o o d4.1 3 >2 >2 <
P-
P_ L,1EVW% rJ T A PE c-
P-
PLOT PLAN: Show loc tions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elev tion 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. i
SYSTEM E VATION U_PPE i wcw- /bZ 30 ~owFl~ 2ENCw -/oZ,/O d_ W
t
r
3 . 3
22
4 ov
r
E
.
/ e
aactr -in V< L67 &~V, _
1
F_ L tj ? 3 /Q0 06 3.
E
E
I
E
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 Wis in
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME aA'RAY nt): TESTS WERXPM OMPLETED ON:
JaN so>, JdN,ssaN~l~v N~ "?Q l ~
ADq~ESS: CERTIFICATION NUMBER: P NE NU BER(optional):
T~0 . $ox 4 I U~~, In~ I 3 1"4 6- OFO
CST SIG TUBE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS E09 COMPLETING FORM 1F - $ -)-6395
To be a CMTi~)li id accurate < rst in€:L,rie:
1. complet -ion;
2. The use,,,,,, ;nt ' vheth a residence or commercial project; ~
1 MAXIMU of bedic cominoi ~:ilanned;
4. Is th'S ci
Corn, A SITE. SUITABLE FOR HOLDING TANK ONLY IF ALL
OTHER SY BASED ON SOIL_ COI ,i lS;
6. PLEASE t= ; prof.' ans and completing the plot plan;
7. MAKE A I your tes Drawing to scale is preferred. A
separate sL, .
8. Make sure you, .rk and qte refei k ice- ere clearly )own, and are permanent;
9. Complete al e boxes as addres, flood p'. "n ;rcolation test exerip-
tion, if a,,10. If the infoz rin (such as flood plan , '-,=snot apply, Er, the appropriate box;
11. Sign the form yid place your curt ent ;our ceri:ifii:.n ter,
12. Make legible conies and distribute as ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS C ,1PLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures ymbois
st: Stone (over 10") Bedrock
rob Cobble (3 - 10") Sandstone
gr &r Vel (under 3") I Lirne w
~s C, Hi
.H
reed s :m Sand l:
F L rr of m Mottles
sc - C;
sir, Silty Clay fff - faint
y
c - cky cis ion, coarse
pt Peat Min medium
3 t
IIVV I_ Rv rter level,
Six ::eater
for fio PM -ch Mark
VRP rticai Refeienc It
TO THE OWNER:
This soil test report is the first step it) 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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
-INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIPAM6L 1+G4QAd.1-TY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
1//E 1/ /TZeN/R19 E (or) Wo ~ZTNRo2
CO NTY: OWNER'S BUYER'S NAME: MAILIN ADDRESS:
>7 C", Ja► rv GEeNFs
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMER IAL DESCRIPTION: PR FI D RIP IO S: PER O ATIO Z TS:
Residence XNew ❑Replace
►~s k .773 Flo , - #Lor
RATING: S= Site suitable for system U= Site unsuitable for system 8 C &R..V-NAeh;T
QrS
19S - CONVENTIONAL: MOU D: IN-GROUNDP❑U RE: SYSTEM-IN❑-FILLHO~LDING TANK: RECQMMENDED SYSTEM: ON4L(oP (optional) C~
S VU D: (•O
required I I If any portion of the tested area is in the
If Percolation Tests are NOT ESIGN RATE
under s. ILHR 83.09(5)(b), indicate: (_LgbS Floodplain, indicate Floodplain elevation: I4
Nc li:~T PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Ild, ELEVATION OBSERVED EST. HIGHE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- b > iI 'QLSL"rS IZ"$eN5(. 76"&,qAh 46e 40 ,tov MS
B- 7- z p6j-z N646 > /1.4Z ! 68921V MSSGIB Z9$eaAS m
B- 3 q-tS /o .iz 6 > 9.-7 5 - C"gL.SLTs 7 4"&WMS /3~,K$eNMS72''$a>J~Is
B-4 /63. 11 > 9.'~3 9 I.ZCTS 7 "9112, 'SL ~2''Ba N M15~t do /SRv &S
B- S q91 /84. o > 9.9Z /6"$c,sL1rS "IRpt 4SL 71S"$aNMS-~'c,e z-'g Gi
B-
PERCOLATION TESTS
TEST DEPTF~ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER yNgN16iJ AFTERS WELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER OD PER INCH
P- z -7560 N I1o.10 3 > >Z > <3
P-
P. ELC-07 o`n! T c-
P-
PLOT PLAN: Show loc tions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elev tion 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 E VATION U, ~ -1 ~ayct~- lOZ 3a k6wFk__1 QENC1A X02 l0 _
Q~.
t 7
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N
40
IN
errs i~ a G~ LoY C~~
14
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4 r ,
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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 Wis n
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (pf intl: TESTS WERE OMPLETED ON: pp
NA2~I~ JON 50 1 JONr~S<3Aj / ^!G ~ 7 l'~!
ADgRESOS: l_ ox, / U Q~ ' rI CERTIFICATE N NUMBER: P U OBCROIoptionall:
U^ ! w CST SIG3 TUBE: 6 a
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
DEPAIRTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/AA1WAFi£.IRAI 1 Y: LOT NO.: BLK. NO.: SUBDIVISION NAME:
1/-E 1/ 7 MeN/Ri9 E (or) W i ~o So~TNFor~k
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
Cea-~A J I GE~NFs.
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: X New DE&RIP 7F77j I TS:
Residence uN~ XNeW ❑Replace L~ Z / 4 Ins k S .73
~otcs - ~r
RATING: S= Site suitable for system U= Site unsuitable for system 8 re1~N~~~'
L~
CONVENTIONAL: MOU D: ❑U IN-GROUND-P URE: US EM-IN-F ILLHt~ ING TANK: ECQMMENDED SYSTEM:
`•O_ e
If Percolation Tests are NOT required DESIGN RATE: /jL I I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: C-4-S5 Floodplain, indicate Floodplain elevation: Q
NC'PT PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Ild. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- I 11• cf~ 7 b > "BL St- S 1Z'"$aNS L 7v"$aN A Ge 46 $,eN MS
I6 LTS /6''i&vvSt- /6.-L k x, M
B- 1.qZ ►z N646 > /-/•4z- 6s'Be~► MS44i_ 39"$eN,MS
B- 3 Q"iS 184. IZ 6 > 9._7,5 "B~.S~7S i9" .,►MS /3~x169AJ MS72'"$a14 MS
FB- 4Tq.,%-5 /03. IZ PJONE > 9 .'~3 9 LS CTS 7 "8Ql,,SL ~2''Ba MS~Gt 40~B2N Ale.,
io">QCS~7S i~ "IBR..~S~ 7o'$aN1hS~~e z~''gAN wJS
B- S 9 97- 184-97 o > 9.91
B-
V-T TESTS
TEST D~~PT-I~I WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER yT1i~J AFTERS ELLING INTERVAL-MIN. PERIOD PERIOD 2 P RI D PER INCH
P. I p N&W ul 16U6 3 > > ? >
P- 1. o tj 3 > >Z > <3
P- Z.DO o b4.i 3 ~2 ~2 <31
P-
P_ L.EV~i oW T L
P-
PLOT PLAN: Show loc tions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elev tion 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 E VATION UP'Ek RJWCW- /02 3a kowFQ`t I~ENC►,~ ~oZ.IO
T___4
/ Z:2~, - f m
I f
I
_$-4
I
T N
I o P3 a
NcuMb+~K-"roP O , v
d'A 1.
o
L L" J~0.00 . ~o 13 I ,
Q•$ 1
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 Wis n
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME 0(p int): TESTS WERE OMPLETED ON:
JoN soy ~oNf~saN~~ev N~ ~o /99~!
AD E3S. CERTIFICATION NUMBER: IPLiQNE NU BER(optional):
_ij 3 f4 6- ono
o . ~o~c 41 o S6
CST SIG TUBE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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SOUrI / Fn 2 k /?c/ ( PLOT & CROSS SECTION PLANS
ZAPPA BROS. EXCAVATING INC
PLUMBING UNIT
f~lOQr~ YIPpP~I°T'/ 1,,.1E
PROJECT
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Sourr~ QRodo box -J17W E44AAJ- NO
low"oelf"r ~iS i~P~ljs~TionJ % o c7T/f Tt.VctFESL+ SCALE
4o-r /3 4 ""Vc A
FRESH AIR INLET AND OBSERVATION PIPE
APPROVED VEI4T CAP
MAXIMUM 12'
ABOVE F114AL GRADE
77
z ( I~--
-I- 4' CAST IRON VENT PIPE
MAXIMUM OF 42' ABOVE ( I
PIPE TO FINAL GRADE
SIGNED:
i
MARSH HAY OR SYNTHETIC COVERINGI ( i1 LICENSE: P 33 9S
MINIMUM 2" AGGREGATE I I l ~7 I
DATE: 1--g 2
OVER PIPE Acq
VISTRIBUTION PIPE
TEE SOIL TESTING BY:
ELEVATION BED W AGGREGATE
•
BOTTOM PER SOIL,.,,,,, BENEATH PIPE PERFORATED PIPE BELOW
TEST IS COUPLING TERMINATING
/ -3o ' FT. ---W--- AT BOTTOM OF SYSTEM
REPT131 TROY ST. CROIX COUNTY ZONING PAGE 1
06/03/92 15:55 REQUESTS FOR INSPECTION WORK SHEETS FOR: 6/ 5/92 AREA: JT
Activity: A9200165 6/ 5/92 Type: CONVSEPT Status: PENDING Constr:
Address: TROY 7.28.19.1049,SE,SE,7,SOUTH FORK RD., LOT #12
Parcel: 040-1217-70-000 Occ: Use:
Description: 149320
Applicant: GERNES, JOHN Phone: (715)386-8995
Owner GERNES, JOHN Phone: (715)386-8995
Contractor: STAHNKE, MARK E. Phone: 715-386-2850
Inspection Request Information.....
Requestor: GARY ZAPPA Phone:
Req Time: 09:06 Comments:
Items requested to be Inspected... Action Comments Time xp
00012 FINAL INSPECTION 2
Inspection History.....
Item: 00012 FINAL INSPECTION