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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER sa yA TOWNSHIP "d%
SECTION ? T ZR N-R / 9 j
ADDRESS _-,$nT ST. CROIX COUNTY, WISCONSIN
d SDK ~j~B ~L
SUBDIVISIONy~y~ j7. ,Pz~ AAA LOT_ Xf LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
'ta. 6r ora- If~'rs-
z I-0-"#ZS
E s y st~.vr, E!= 9 s. 50
S«I~. by'~ /D~
Ted
Gar na.f IOb. D'
j
r
dw.raJL J~
~v ~x.3 s' A
N
-I N
140 u Sm J0 XSD'
,
we-1 ► 40
8° z :o' - - - - - pi
. O o - - - - 10 16' 1
v
tAf 30
INDICATE NORTH ARROWr
S/7
BENCHMARK:Elevation and description:
Alternate benchmark T64 -ag AR /e C k- q""&
SEPTIC TANK:Manufacturer:wa;_< / Liquid cap.
Rings used:. Manhole cover elev: Final grade elev:
Tank inlet elev.: 17,11 Tank outlet elev.: ~e7
No. of feet from nearest road:Front , Side , Rear (k Ft. //V
From nearest prop. line:Front , Side , RearX Ft. /00
1 i
No. of feet from: Well 19D Building: Z
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
t
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: A J/ Seepage Pit:
Width: / V Length 7V Number of Lines : -3_Area Built '7ze9Sl ;7 T'
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: Al?,
No. feet from nearest prop. line:Front Side , RearxFt.-Q
No. feet from well: /DS No. feet from building S z
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 : PLUMBER ON JOB:-
-5, LICENSE NUMBER: lz
6/90:cj
a
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
. Labor and Human Relations INSPECTION REPORT Lot 28 St. Croix
Safety and BWildings Division
(ATTACH TO PERMIT) Pine Grove Sanitary Permit No.:
GENERAL INFORMATION NE4,NE-, Sec. 20,T29-Rl9,Prairie Ln. 149168
Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
1273
TANK INFORMATION ELEVATION DATA p 9/
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic OV Benchmark e - 5,17 i /pT, GZ>
i
Dosing 13, ,(D 3.¢3
Aeration Bldg. Sewer
Holding St/-Kf Inlet ~l ! 70(0
TANK SETBACK INFORMATION St/M<Outlet 7 G,,_IO
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic ~ ~ a (J NA Dt Bottom
Dosing NA Header4-Man. / 96•~F~p
Aeration NA Dist. Pipe 8,~3! 96,3s `
Bot. System X33
Holding
I
i
PUMP/ SIPHON INFORMATION Final Grade 5,531 g erl
Manufacturer Demand
Model NernVe-r GPM
TDH Lift Friction System TDH Ft
Loss I-f
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width r Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type Of Co,^J r+ 1 CHAMBER Model Number:
System: Le Y, A OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing 9~ /
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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
CD 4 tec~ 6, /axje_.~ trr 41,~ 0-ip r 4X.-OX
Plan revision required? ❑ Yes to /
Use other side for additional information. ~d IeA N
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
7 DILHR SANITARY PERMIT APPLICATION _
In accord with ILHR 83.05, Wis. Adm. Code CouN
STATE SANITARY PER T #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑1 q 9' 1U
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
.Sa *l A, Ar kW~ 114AI a S T , N, R / E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
w SS/o/A 3Fl 7Gr/ wg d~- 7~
CITY NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLAGE
~i : ✓ i a- /a r E ]Public IR 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX N M ER(
111. BUILDING USE: (If building type is public, check all that apply) /7--7,3
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. ~Vl New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
I°1 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 E1 Mound 30 El Specify Type 41 El 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. tt.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
ysv 72-a -7 Z f 1-3 g.SSO Feet 9Qz.7U~ Feet
VII. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank ~D00 s ' c
Lift Pump Tank/Si hon Chamber El I LJ El F] I F-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:
S L 7 3 z-3-7
Plumber' Address (Street, City, State, Zip Code):
P /Y
~T S
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater s e Issued Issui g Agent Signature (No Stamps)
Approved ❑ Owner Given Initial / Wye- Surcharge Fee) 14
Adverse Determinationi 140 1JA-1i
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
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.
Owner of property
Location of property 1/4 1/4, Section acs , TAN-R~
Township Mailing address Z_-
47-7
Address of site ?~s;
Subdivision name 14-4 f-3 Lot no. 27Q
Other homes on property? yes No
Previous owner of property
Total size of parcel -P.,Op ,Qf,
Date parcel was created g' 31- I0
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for (spec house)? Yes No
volume'16V and Page Number -73 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. I/" 11 / 4 , 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 }n the office of County Register of deeds as Document
No. 140 fq
ignature of applicant Co-applicant
y- q-
Date of Sign ture Date of Signature
FORM w" ?x 14~•.D -
- g ee' tS 1~ f~ 4!k,4~~
ac ~ ,t.`4`Y~T r, ;i ~•r'Y43~A ~'IgtiCML~ ~ ~ ~ t'r`S.zz is b~ 9
~ ~W
a~ ,w...; , K..,. C«aahAS'. whellsax one or~~assd. x
Abu
• ` Pure. the following proPerty. ~ with tae tt a g + y 1, `
ce of tltiii voauwt DP t .i
l~cgDQss of w appurtenant iat~ W esned the -property").
: rUllN TO ~,#k7,~,'+'Yr
eS(?I~X - COnntg, State of WiECCnBiLL tte
33, 35,36 Pi.uegrove iteights ~ P. '0. 303 ,A".tion the TQIM of Hudson. " : .
Tex
~i.,. ~~'b - <'~7 Ate' -~k~ ~W
~ r~ >°l~t:: homeatexd property
(ti-Dot) r ^-i 'H''4Y1.
to "purchase the Property and to pay to Vendor at _ , r
~~~'4 QO _ in the followir►gasanner: (a) ~.-•~rs-r i'
and, (b) the balance of 3.iS3 1 OQ_tOgether d ith interett',
atbeEtius x24
Contract
;
from time to time at the -TatO OS
r at mss. P of M Q,000.170 bef a Der 31, 19 ;
3 pCS of $18,000AOe 1}91r~_
?rte ~a
$ P®9MIts of $18,000.00 each =1* M;•&U of< emc4 p° '
. s ~ mat" of $'.g~~'F.00 , ~ 3~ , ~~~r~ Via. ~
~t6~y R ~
i an;.pcincipol ft PMVMAW Wi23;aft,
too. tl~. ~aymeat to be anke on the In d,sq of Ogtnt t' "90
ft First
r fioic, p .month, inebAirr, ad #x, F •
tstamag balance shall be paid in fall an or before tlss e~. .....r~u► { r
(the maturity date).
annwa on the M*e0}
Est; inter04:ehall accrue at the rate of .......Y. P
f5 ' llmltation de21a9uent interest and,. upon accelerttion or maturity, + ¢h
monthly to Vendor am
z;- t
when due. To the extent .tee ,hP Vim,
fire and required insurance premiums acre"
nts recalved by the Vendor far
,~1pe,nnta to these obiigatlorts when efts: Such amou
w`
be ►ted into an escrow fund or trustee account, but Shan not bear l~atept►t
depos
will ' ~ ,
3seR , ~ ' `
Aav~:
xb
withoat pramisun or lee-upon principal at an time +
,rr
I Pot
thin Contract shall not be treated as in default with respect to Psv'ment so long
d►ts # swstt of Jay rmwid. of sad latOr"t (and is such two accruing inters A from mouth to month shall be treated ~ a
MVW s;
;W6tjpal): is less.•than the amount that said indebtedness would have been had the monthly payments been
Q ;yDsov that mthly payments shall be continued in the event of credit of any Proceeds ~
excluded herefrOM.
4em%mustion.,the condemned premises being thereafter. ,
Uot•Pnrehaser is satiaued with the title as shown by the thlo'evidence submitted to Purchaser
ins sotaat~sdes- aaedatian of the claw pery~tent apecfAd i i+b, one of the AM 'Low
:ftl I "1 1. in, pert woe of this pontsact. 7Y frtrtheac agzee that
p=bmw
RY ~:~:(t
of ea& of, ft.M,=OD Pftw tt on 7iflc1Q1 ~ above }
wcse~;;;~t.adl~:6t'~e~'~160e4d ; open neoefPt ~,f~the$5,124.00. ~
~~St . ~ 1~'~ be ooaveyed; on neoe~pt oki>t2ie .£s~ Pte''
:i a4
'AUe is Dee ms. It title evidence is in the form of an abstract, it shall
. x "Y the Cost rice
•°aatil-fbe fall parsoafs
D th® date hereof 19•
kY } p }g'ahalZ,~seadtledto talcs poweaaiDfl of the proptrty Ott..
5
roa! Blcxit Ca,.lae.
~MPtltll~t< r
tin eAa:.or ~t.~T~tt~..
44A- 0.-
Purer proaaioea tsI pay wbm tine AL rasa and ieratstium. to levio&40 t
D Seth pain s. X'#&
i 4' ` tv doeliq~C ;Vere3oc Q04a=M;d'weogvu abo►►ntc
III all lip
M =-2
r
k . ? -oplgaalfilt> i tQ am-tt *^At am snow paste to be U00~~w
t k riaa
afteting the
PMONW.
IMP
west and othre svoess shall be
i d" ie acs tl►e.~rSl a~►,. M. '11~t ~I
'~doo~i. as ua dxoaz ana In di* witk iF. Awn 90601114 VISa
ot..g iis~d"
.tae Putrst~at~s•. aF W rsantr -Dead.' in lee .impAG► of the Property, flee and 41M
" ljgft oT@ ' rptitby the bi act or .and'ooo[at: J`w„•~+•}~~?~ r
..tAe event of a default fa the Pgroosnt of as7'
td,at:#tae is of tbt oneaoe and (a) is
-Ma data ,
P~, s~~ co~etitr~''lsr ae 1 ~ --'~...dayte fe(krsri~ the ~fled or`Ov., ia'tbee~'to~sfl~M"'
period _2%_
a 1%unhaset which continues fora of dais d
'oafzsaY galirr ~ aztifSRfl mail), than-tearirec ,
t lwr+elt b~=, (daR~evered
due and ,ai a and pa os mailed by
al:all be~~,' taamy` yaW is full, at Vandor'$ option and without antite. {which ~
rda acrd y r;adsslI ~ have tbo following rights and rento13£es (subject to :snY limitatieans'psovtdeda
e di an ro ed b hs►oria ~Y:• (f) Vendor rosy, at bin W5^ terminate this cwti"~Mdll
. i r c. w, tWa and..iiAt~OYt in the nv and, recover the. Property back, through itr9L't f0
a i~pti r, ate omditioued upon a full payment of the entire outstanding balance, w►tb,latsrwt:
the d oY 4datsft at the rate in`effat ou such dateandetbwammntsdneha omder(inwbicbemtAU smsonaiM
p~d by shads ho forefeited as liquidated'davages for faiivse to fulfill, Hair Contract sad 80•2 ~R
pwaaae~r
t Property i£ purchaaa' frila: to redeem); or (ii) Vendor may sue for specific performance of this t oateael: for
irsenediate at~i fall piaymea?t of the Wore oa4stamd#ng b"o% with late itbereon at jadiefai Baia a
defs,& and Pmaouats dtee . harearedtar *icn ar]~h; tt the 1'1wpe j►
~ skull bs:l~Ib1'r for un.9 ae~i~es'' ~)~'V:naa'Y.~ st law for the w~ro Datrelrase yriCa
4Lmreof; or (iv) vendor'ssapd arrt Coatrapttstaaeod.And Topove this Centractas$cleud on tWe-A
F;;rtiara! S ~ho *quitable`tatevil aL:~ 3s-~; and (TY vasdar may have Fwrebaaar ejee4d
Q of tba;' rGy anrt Stave a, xeesiver a~~gtwvollec~ any Tanta: isinsar or pof5ta 4GAW the D
....mar {{'i?► (ii) or _'~ve.AYotwr nay anal or written statevonta orlaetionsiof Meador an e
}
1S oUthe temolo remediesatmll only be'binding Upon Vead~or if and wt= pursued in litigation and Wean"
Mod
includi~F t"aoaable .fasa of VrWea miarftkt to sit= waY ¢ Y besrlaadst.
extent nlxL pt~6hibited b7l and si titre eviderree shall bafied 60 s»d }s+fd W
carzad, a-34 abon :i. ij~ i~. ur 3. ' . 9,;•= ~1~S a~ * T'
of sMy
dAthe`A"winumentof.sireo>•hwOhcsnesteedinterrat,to Boll CO~le #bal~
'durft {
the l3sq ► and NCR FYq~. 1~IWtK» sad Doti *ban so
T'.
ArAmw a,
e :a i0wi k~ H''~ 9R Other way
r t of 'o a'+l is under thin t=kr A or by optina+ lam any
ee
o~ • # L1wov skis 9*dW t * Contract is fuast.pddaft ft s
y ; casveyed lam. pledge or aeesnst adsm►''s +C°Y asotely. a ~ssa~lM toe 1INs
t Y Pumbaza-t* the ant of any such traatrt'.' dr'caave7aat=e Meet
S € . balanao vaE~able,under th6, ~ishatl boobaue dace pay" M tall. 9 'opliott a •
t rt r m Xbnll *twm Am'vn&r nines 'w~'ussiast Yimsst taw ~r~a~•eR Mt
Co~zraxt'(mrovat'for aniy matt, Abp parebsper) -or under any note Pecared tbarrDTs'~
ad r iy poy>tof t1s0 amouass due under th§a Contract Purchaser may make any df `i
bq Pwvbaser *hall be
F x the
subuoquant'ar ' Rbartgact~e. i1' Vecidbrr 7Ia118 bt►` doArro iba ail? zasmts a0 prior default Purchasm
this Cuntxact
Ot nl6Y rWAi9e, Ct~' a2tPiu,t wfi.Q'a iE
' Ail• ~ernnr'.o: tl .`t)oa~t, : x .sbsiF' ibla' b 'sad sauce to to prop is of s b legal
q
a of t'ar~ and Pattrltasst. (it n -of the Prapar tg► the spouse of Vendoa.91
Mal
` 1 o td to ation fo~or~ir .a rele~aae bsuncesComcl ts fn sue' and Sven to join in tbs,aaesaliaa~
r 3n 'be mssdessa ~a3.~llrarc~t bee~l 1
a IMW IN . day of
~ , .apdt ton by "
.(SEAL).
► u » f `
rd"
s~ "3~1 ~ = a. r (SEAL)
» ~`....g~W..Fiw..~i3.~~..SX..... ~ ~ ~,,,ip♦ 'L~,
6 Y y ify, anat i Stout-
A#vsinNT1,*'ATY0N ACXN0WL3VOUA'bt
3TA'i"iz 08 WISOOX$IIi'°
.i.
t authenticated t. ....daY of„_._»__._...._ 1i_- Peso came before me tbU
TITLE: MEMBER STATE BAP OF WISCONSIN
(it not, r-' +,..4 {N,•
suttwri" bJ ! 4 706A6. Wis. Stets.) w who~tt da'
to aaar known, to bs t%* pdrroaa .
< f t and the $a=&
t THIS INSTRUMENT WAS DRAFTED ISY - *
r
, .
(.~.....a `(2 : Notary Public
(Signatures may be authenticated or a&nowledged. Both My' Cotamias:on m permancnt. (if not, stabs
are not necessary.) date. .........M ........it
~41ftims.
y t y i J
1 '1("W* of yertMri *;Th1nR in a6y (""Mr ""W Df 't;•D~ or ~pt $wir• a ~ ~ -
.S+.s. +.~r'e e~oxs'a,~t~t+~.tslRRi+ire~4~ 0[ V~est1P+I. ~i R9t<S ...a ...a • AW« }
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County
n
, t-%
OWNER/BUYER SA 40/
ROUTE/BOX NUMBER Fire Number
ZIP rho ~
CITY/STATE
PROPERTY LOCATION:Section?-:51 T-1,-?N, R
Town of St. Croix County,
Subdivision -Ee G40d~- *~f Lot number_ z y
Improper use and maintenance of your septic system could r esult in
its premature failure to handle wastes. Pv
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed''s'e t-ic tank um er. What you put into
the system can a ect t e unct on o. t e•septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents•may be eligible to recieve a grant for
a maximum of 607. of the cost.of replacement of a failiing County,
whi.c was in operation prior to-July 1, 1978. St. roix accepted this program in August of 1980, with the requirement that
owners of all new ~sJs- agree to keep their system properly
maintained.
The property owner agrees to.submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater 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)•a£ter inspection and pumping nec
essary), the septic~~~ikbe ssentless
apthan 1/3 proximatelyfull 30fdaysdpriordtoc~.
Certification form
three year expiration. y
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as-set by£the Wisconsin sDepart- :r
ment of Natural Resources. Certification
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration.date.
SIGNED ~ ---~C~~~~
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016.
386-4680
Sign, date and return to the above address.
INDUS RY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
' INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADIS
ON WI 53707
HUMAN RELATIONS
(ILHR 83.090) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/ LOT NO.: BLK. NO.: SP1K1F_6#'0q& DIVISION NAM :
N~ 1/ NE 1/ Zo /T-z9 N/110 E (or W / ab a 1 -Z!& Wc-
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
S-r Ceo , x SAM M,LLEP, I-Q60T $206w<io'0 -at> /~(j ZS6 i
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: IPROFIL ESC" PTIONS: ER 0 ATI N1 TESTS:
I/~Residence )V_ - XNew ❑ Replace I! -712Z g 1 7 24 CL/~
RATING: S= Site suitable for system U= Site unsuitable for system "'31 C-S
CONVENTIONAL: M IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TENDED SYSTEM:(opti.•LL~iJ~/Iopa )
VE~JT1O)J A
s ❑u 's ❑u WS ❑u ors ❑u ❑ s ~I►
If Percolation Tests are NOT required DESI R, E~ : ' I If an ~
y portion of the tested area is in the iVN
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
bw';k PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IAN ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- I 9.67 /bo~~ NoNE > 9.67 0'91-CIS z)" "S,c 7R"8>R.jMsf4A
B- 2 q. 1-7 160•1~ /J6N G 7 9./7 / "gi-c s -0 8Qn4S1C -6) "ge" mSj, R
S,FG~2
B- 3 , 3 99.Z9 N6 NC_ 9.x.3 /-6 "E 4krS 24"8 NS L " N Al
B-4 1/6-a C? 0? N r ) O-lot „8/ " S.L
B- 5 /0.-n 9.45 NeiNig > 3 3 26"' g«TS 2 a S, C 7 AjuM'S el k
B-
UCS1 PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD2 PER D PER INCH
P_ I r, •3o No E )oo.~so 3
P- Z 4 70 No ZO 3 > Z 2 > Z 3
P_ C6'O w o,,- 99.30 > 2 > 2
P-
P Vq'T io d'T ERc
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 45•So 0- bMdP_L'4 I: P'z'"'R1° L Qv.
TW,% LANE
3a'
WN 46 - t N
100 R PE AT N
r.jA
V 6
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:
A 0)~N N SoN SC~~e ~Y/N JULY 24 /99/
AD ESS: CERTI (CATION NUMBER: PHONE NU BER(optional):
. .$ox I 1~ ~N In/, S4o/ A34 i2s-6-40d
CST SIG URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: WWTOW NSHI PLOT NO.:BLK. NO.: SPDIVISION NAM :
NE 1/ NC'/a Zo /Tz9 N/R19 E Z~ t 1aadaov~ 1 4-rs
COU=TY: OWNER'S/BUYER'S NAME: ~ ING ADQRESS: ^ D
-SAM M,uL1R acs
USE DATES OBSERVATIONS MADE
11.
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE ESCF~IPTIONS: JPERCOYATI91 nNTESTS:
I,gResidence UN~ - *New ❑Replace 2z. 9 7
24
'Sw" &6"e' ft si <01 is 51$ ►T"'Q1`
RATING: S= Site suitable for system U= Site unsuitable for system
OOSTI❑U . NIO _S. ❑A IN G S P❑U RE: SYEM-I NaFILL HOLDING T : RECOI~(VI WviSOT DMA14 1&EI~
( RATE:
If Percolation Tests are NOT required DES If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: wad I Floodplain, indicate Floodplain elevation:
hwi PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH WV, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B" 9.67 ZS1 NONE > 9.67 t?'i C TS Z/' ij'$v4 7%784-AS44A
B- 2 g.17 60.1 (JINN ^ ? 9./7 "BCL-M NS,L `W) N N MS119 14 B- 3 9,q%3 99.29 nlc _ 9-~3 "1841-TS Zq"$ NS, C " N S 440,
B-4 16ta 9 e4 "$c.LTS 'r Q s-L 44''juv/~ 4 e 419wM5
B- 5 /0.33 9.95 MN& > 16.3 3 26" OLCTS 79" jqMM55 e4 k
B-
tsECS1 PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER OD PER INCH
P- 1 530 ONONF-11106-io 3 >Z ~2 P- 4?0 / O > Z 7 Z > P- 99.30 2 > Z t
-3 %6 P-
P- VA.-T ,6 A-t Ekc-
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 ~S.S4 0.Eu-cekl'Q1:! N-Ai t,d LAN,.
a_
- -
i
a
E
E
E
4
/
F
E
E
1 r~ ► N'
~ IQoU >P~ A7
3
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Ilk
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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 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:
N ~6AJ<54W N SaN S6'e Z;Y/A)JGL Z4 /94
AD ' ESS- CERTI§CATION NUMBER: PHONE NUQII~ER (optional):
CST SIG 434 URRE: Oy 4 c]
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
ILHR-SBD-6395 (R. 10/83) - OVER -