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Wisconsin Department of Industry,
LaborandHuman Relations PRIVATE, WAGE SYSTEM County:
Safety and Buildings Division INSPEION REPORT St . Croix
NE, NE, 20,29,191ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION Lot 36, Pine Grove Hght. - Prairie Lane 149142
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
Sam Miller Hudson
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
1671
,ezl TANK INFORMATION ELEVATION DATA (0/1
~ jj
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic CcnC_ Benchmark lo _3
29 3• /UD•G11
Do ' t I
Aeration Bldg. Sewer met.
Holding St/ Inlet
TANK SETBACK INFORMATION St/ffi Outlet LIZ'
~p
TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet
Air Intake
Septic ar ~90 ` )14 NA Dt Bottom
g NA Header/>A&aw
Aeration NA Dist. Pipe c~
/0, '9' Yoe dv
Holding Bot. System e 91"r7,
PUMP/ SIPHON INFORMATION Final Grade ZZV' SSE
Manufacturer Demand/
C
Mo um er GPM
TDH Lift Friction stem TDH Ft
Forcemain Length Dia. ist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK
INFORMATION Type Of Qx.;n CHAMBER Mo Number:
System: C~5 /jd, ~5 1~OR UNIT
DISTRIBUTION SYSTEM
Header4A4wtl` 1d Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length 1~ Dia Length _3Z Dia. AL Spacing 4-
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over QD1 Depth Over xx Depth Of xx Seeded/Sodded xx Mulched
Bed /Trench Center j% _q Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
96, ge) -6 - cmx-e4
vc~
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 1161 ( ( Q/
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER S5;mm ~i (~d r TOWNSHIP L`~ c s o v~
SECTION ZO T 2'0- N-R ~j
ADDRESS $o>L Z ez - ST. CROIX COUNTY, WISCONSIN
SUBDIVISION Gro ~~i~S LOT 36 LOT SIZE 2. 09 41C,
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
{~;r~o" 6ro va Lots :SG 5y5'f06"'k r& I Y.= g2.00~
e-^ I& I/., 'S I'0I /0-)feCe
J B.M. Te( JRoh -A,
k 1&--4 x S Lorwar ~vfi 3G
ya, ' I rr ,
D
h I `I
L45'
yo -
N u a--
Sv'
,Noll G""`~'~ yxu
R
_ i
I' E
~s w
A
T3. N1 " y INDICATE NORTH ARROW
BENCHMARK: Elevation and description: T,' . c l rnn ;Z~ss G~HUr F~= Ioo.o"
Alternate benchmark: o ~ iau6 4 = • 3 ! r
SEPTIC TANK:Manufacturer: VJ&~S a-,r Liquid Cap.L T)
Rings used:_L_Manhole cover elev: tP,77 Final grade elev: 7el
'
'7 Tank outlet elev.: 11:57
Tank inlet elev.:
No. of feet from nearest road:FrontSide , Rear Ft. 1+5' ,
From nearest prop. line:Front , Side( , Rear Ft. ~d~
No. of feet from: Well ('P-a , Building: `•D~
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
t
~I
~t
PUMP CHAMBER
Manufacturer:A/0- 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: bon . i",k~ Trench: --'Seepage Pit:
Width: Length y0 Number of Lines:. Area Built 7Ze;'sy
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front Side
Rear Ft . Y7"
No. feet from well: -7 S~ No. feet from building
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:
Carl,
DATE: PLUMBER ON JOB:
LICENSE NUMBER: --E
6/90:cj
SANITARY PERMIT APPLICATION
DILHR 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 9 ~y
8% x 11 inches in size. ❑ Check 1f revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORM TION.
PROPERTY OWNER PROPERTY LOCATION
r--% IV46 Y4, S o T-27 , N, R E (o W
PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK #
Z 30. -
CITY, ST TE ZIP CODE PHONE NU ER SUBDIVISION AME OR CSM NUMBER
c\
LAJ T
5- o /L LZ vr~ 2 mac, 6 Ts
L.j
CITY NEAREST ROAD
11. TYPE OF BUILDING: Check one
( ) State Owned 0 VILLAGE : O
❑ PubliC ~aj 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) /A p,
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 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. X New 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 P, 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) q ELEVATION
41 5~ 2-0 7 ZO ,Ii 2.S L a~ Feet / S • VO Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total of Manufacturer' Prefab. Fiber- Exper.
New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank ~B #
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): Plumber's Signature: (No Stamps) MP/MP W No.: Business Phone Number:
its Z~ Z Z
Plumber' Address (Street, City, State, Zip Code):
422 . 4 h.P r
IX. LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater a e Issued Issuing A nt Sign re (No Stam
Surcharge Fee)
Approved ❑ Owner Given Initial 9
Adverse Determination r / t • ✓
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
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_46!!~ 1/4 1/4, Section Z0 , T:;~_LN-R / W
Township 'j~x',IA'n~
Mailing address
u ~G' C.cJZ S ~'Df !e
Address of site Cass; ~.c„
Subdivision name Lot no. _.3
Other homes on property? yes No
Previous owner of property
Total size of parcel 2 •O ~r~
Date parcel was created g- / - C?o
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)?, Yes No
Volume j go and Page Number -7 3 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. L( ' l %l S
Si ature of applicant Co-applicant
4
Dae o Signature Date of Signature
kill
4'~ < d y I
{ F Y ,.~~1f
a"'t'~1 ..f_:, tl~ ?..•z~s~ .t`= R 5 3~i }'-,~~,{w,~~.l~:~ ,Y.q. ~ ~
,,.,s• ~fi n.>< i z b . ' ~ -...+.err-»- ~ !'.~'r~."'t"`.~.''►`1t~""b",,~a ~k.i! S~(; ;
v~G$~t p.w" 6 Y tW fi.i«
i~f 1► 021Aal t~EP► E y r g y
Men,
to pitrcinxw. II~,the prompt srd tM
Ala t ~
r ,oY L art b? r Lhc followiAC property. ar{ h t a i y z '
Vropta; otber int es! (all-ca1UIed
32, f 3 Y, 35, „ ~6 Finrgrnve Heights ~ .t?
d
~r i~5"rIYT ,Kud3ou
1 f•'1~~ ~ e ~ ~;~t3,r ~ ty rr.J. AX rPaIC4a "3 . .
e hf a
,,gy~pp z g~g.:~?t,' ZI,
re.+y~ ` f d? r x f s Cq
C + r -
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~1,+,y yA pNf-~' I .r Nth 4 ,l
'B'AS f'r j 1 I' }.t ht1 3'
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homestead property' ' z
-to p~~,~cs?~tjtnr base the Property and to pay to Vendor nt .:.fir` ~'44 t
".3.:r. 4 'N... » in the following manner L. { to?
113 12 00 to~eti~ ~i~' „
~;~.aad ,tb) the. ba1,►ace.oi S. ......,:...,...,:.1_,
;a~time;* tinge. a♦t~fth~yey~rate ~of..~~.,.,,
from
-of $18 000.00 before L70 •~4♦ 'L°J3'4'`~ J-1'~~ 3
s tri F
M{
->aec~.199i,.
t ~;pe~eoenta of ,$18,0OO.00-
a of $18,M-00 each. dutW'M; ell of e8d#-
~
-h ~ 1 lY --p .rr, , k eae~ip~ '~1,~ iM
Ix ak .L . 9~eegneaL S«
t) ~ shall be paid in foR ors or harass tb? j
w ,f, 5 Y' Y rt7Pa`-rYp►F~KM7 date). 1 k 'r'!y kfr k, k,~ ; °.4+•
lam: shsu accrue at the rate of.:ai•~:.. % pat'; .
interest sad, upon aceeleratfori ar ai4tari
t C0liasitation, 4ellngvent,
n9
griatreea:o paT iapnthly to Vendor:amounta snfficieri~, > re
and
tkt +d x n ins ursaft vremiaw'w~ ea duwTo.tbee~tent.
to then~+ obti~atl~ne whew dna.. Sucksnwnata received !q t6a VeMAO6e
w}g.kl4) ted;into an escrow fund or trarteQ aeoonat,;but h&U not
s w ~ IffM' or 'lee upon principal at asy time - ' `S
N
to paymjestt, lp , QW
' ' ,this'eaadna Sb&U not be treated 'as in default erith respect
` ;end inttnest scab' dtse a► ir+g inbear,t from month to month shall.be2fieab~~
indebtedness wonid haVe beer' ball the monthly pxyments bebtt , +
eisF`t~ftgt the assoont tlst said of credit of any proeveda
aban be eainved in the event r~ r x;r
-jwovkWd tha►t.maethlT Pay
the condeamod pranises being thereafter excluded hereftorn. i y
_b Pi~ebseer 3s >satie4ed with the title as shown by the title evideace submitted to Pnrchtuiar ,
f~ :coos. of On dooms pmt specified above, one of the above LOW
of titia Contract. 9 agree that'' 1
40.?"vocbmw in } of ~$16. Q M payMECt on prinfurtber
cipal specified ffioas
"Ceipt ' as the ~l .cC the $ 5,124.00..
Lo~vJU +bs eoereywed>flaaeceipt ppy"'eat.
7A,5
evidenim. TS Was evidence to in the loan of as abstract, It shall
due
3eaQartt of t3te Proparty.ai+. the date he
19' 41
t
a taam aad v43"ma"Mu larvlod on t$~e ~1fa~fT aY' ~1 "!Z
i Puretzas+rr ,`Jfa9ie to m n am 'a s Y•:
i~ #o dehvler se Vemedor en dwn+astd .aeoetVU rhgering d Past
3 ~
s ~r. tTC i1r OiDWa a"n0~ tQ^00raYalt wliatt rWr &Dovr waste to t» committed o7s tll0
fteperty tt*Am Ot try{
fret free Be. tupe'lo' to
ioerp the
oil
to cedar` oedinanen and regolaU." aaeatwtl the Properb-
~+aa~ot tl►at in es: the Ptavilass price with interest and other n~" shall P6anw
rt•. saseals x~
at the tine and to the sasses' above spuded Ve JQr will on
t_bq pwabroer: a Warram De*sdr tR fee s1MP* of the Pte►PMV# ! cad el r of all 1Nos 'cad asw~! *
by the eat or Anfault of
f ;M. r+ a> saemsuto for ubutil . ` . fry
4y f` ` M'+'K ^T^_.•'.~...';.1T"y rw _ 1 t ...h .
t N i~r. p y' t time is of the essence and ,(a).~in the *vrs►t-at o default in the paYrreat'of am"T. .
in4ts-est h~tinnss foe a pxsIod of_.:days 4oibwiag the specified duo dam (b) tLa'swat
of Purchaser which continues for a period o days followin rte.'.
xala~nce-of ally 4 ~ Irataaee undue teM°
Vendor %ddh ed personaUy or d by certified mail), tben.thsaseSre°°tstandiug
ahalt become iv=sdiatety due and payable in full. at Vendor's option and wnttwnt notice {Wkidh Pm
t 'tetra), =d -yB-zdor ab4 also have the following rights and remedies (subject to any limitations FraviMd
mdditiara: 1>boee~ bylaw or in equity (i) Vendor 'nay, at his optionrough strict efaaedosare ~h
bMCic
Yfg:tt>s,' two anal' C in• thePre and recover the Property
a#e Um ,to be couditiouod iron Nrehaecrru full payment of 'the entire outataadi balance, with interest
the dare.od defse8 at the rate in effect on such date and other amounts due hereunder inwhicheventallamoaata
. p by ?=ehmer shall be forefeited as liquidated damages; for failure to fulfill . Contract and us rr
` Ptoper~fy if pnmhaiser iW7a to rmdeeza) ; pr (ii) Vendor may awe for specific periorm:.ace of this Caotra4
ar immecliatia s>rd tall paym'lt of the entire owtstanding balarsce, with interest thereon at the rate in effect eauYtYe; daft
said otbsr Diomnts'd" hereunder. 'in W)dch emt the propmV shall be auctioned at judicial sale arrd
z v aIl>i►i: be liable for aerly deffcieeir9. or Vendor, May LIM at law Joe- the entire unpaid purchase juice or m
thartof; or (iv) V way declare this Contraet;at An end and rertwve this Contractasx~dcoad on title iA a
ice of ?ardor is in~Er (v , V~or may be" P eS~ fanner archaver
action if ~ait==441
of the Ft y~ftd %AM si i*0 ver is a►llo~ any' Tooth iWAM or be pssad~aoy vC atl0i
s i) (ii) of (ir ,'abave.Notwa any otd or WrAtais tiotw:of V
of'the fo~oirng-rem shall only be balding upon Vendor if WA wt . +nrs in 11tigat3ea cad L +
rye. eelu nr^xeareorrsbb► lses~6~dy.;VVa*d*r msulred taimftmv r~anT 7 he~sder ~('rlebur 4004,as"~R .
P~7
e 11 . not pr0laBd Of t1B lflidenae liana be ade3ed to prinefpet =4 J
~a~ r ou gew-`be iti 1 _ of this 4iMLrvdVXM
r. of
f.. lOpo:t lea a d b,= Interest. to Go" the
r arlp0iffi t'OS a ~rfgl At the, PAW
• when a0 Da0ACS
Pro ~y duxmg t~ of asteh action, nod setMls. frees, cad preAts
the
t'~i~ppliesl~[,r~ the cecs~~tl'a.lrrml~l o- r r iateeesC'in tiny ~yy
F4 {4 .3 +M' l~'tK ~sT 3' l.w ~T ~ ~s
lea" ar any c.. wV Ibi 11 1:.
r 1.3 f3 lPUrchX60r 6. rii:htE under WS Cooatfect or by.aption, long-rd in !+¢g
ar'~t#It°
' ` " cams t'ad r a -tht oukspandarsr.bahkaee pW&e urAer this CAgtrract'ia'fret I"
bAm"t We+iiiw" cout aotvdel ; a`, 9@637=7 ;FM esq
' Eon a gi ae ai
Ttmm:F~r. In the *"mt od t mf, p " a» t VMifles' yea `'R1pi0 t~
a m , bl* under this Caract- shall become btv"diatelY dsid payable i.! fall, Vr i&W-ptWa~:
" V sbaa2 ta'ia all peg' vkan due ander sow- mcrtm+ O ~
^-Wx C` ;1&&RC (e= VIA fm any Uri me gr anted by Purc=er) or under any sate aeaurtd t yi°"
nol.-ea tbnfily paymmt the SMIGU' " then due under this Contract- Purchaser >n>kY snake and
the M,.4v~r~tcmgee if Wegaor fails to do w4nd all pavlel" so made by Rirahaset shall be P
L9ia ~wt•AG$.-
t ~rmcins .znayt a siv e' any dE colt 40wo 1 imiving any.otie r subsegeent or prior default of Parchsae>G w
I - A1]' ` 04 - iPits'Coatrnet' alsaTE' ;3aE' 2riexliag upon and h mm to the beneaita of the besiza,
,':c arse :and ~rs of Vem&2+',snd Parehaaft. (I11 owner of the Pr ~ ~e~ oil A of
r;d,*rretian ;r r ez+tit to rqlloas^ hamert"d rights iu Mrb3ent >
t n dead to be tsadie ix tu;•~itlnwat hwa f•1 s
_ k
dated taus' .I day of ..~:,~~~.~i.3.~L....... _...~._...'if..
too ay
~7~x'~rs i. ~i.i.~1~+t.rr .~~w~~...t+.ci._-.. {3~AL) -~1~ • . a31'~,~~'f~l•F3~.1..wyac
h , " _~C e , .i.+.~~~g.a"ate
-~H} ....(SEAL)
y
-
S ,tl>- f Jest P. SLaut ' ----~-E...?fy.Ilet A---~~:
NNOWLSDOMUNT k r »
AUTHENTICATION A C
STATE OF WISCONSIN
Si afazre(s)
{ ~ ~ q ..._.....c4m y, ace. 5
authenticated this day of , 19.... personaUl cam" before no this
f.rr ±
( T1iLEt MEMBER STATIC BAR OF WISCON$IN~ '
authorized by 706.08, Wis. Seats.) ho
to me known to be the W porson .
f ' f ing i nt cad ledge the atanMk '
THIS INSTRUMENT WAS DRAFTED BY
h : , .~Y Ta"i Di.51 4A 5401b............................. Notary Public
my, Commission is permanent. (1f not, staff
ff (Signatures may be authenticated or acknowledged. Both
are not necessary.) date: .
•NUPAM oL vdrsw u*uiw in any ftwuF'ekol" are SJI a' VA" ydew tlairKlta~luaw
r.+wa-CiDlt'r'CAC?•...end,~i.~i~~f:Faeislre.]r--tom
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SEPTIC TANK MAINTENANCE AGREE11ENT
St. Croix County
w
n
OWNER/BUYER'~„~,'
0
ROUTE/BOX NUMBS Fire Number o
tt ' ',[for' ~~Z. d
ZIP
c~
CITY/STATES 'SAM_ W~ n
N, R_IfZk
PROPERTY LOCATION:*.A/,F_k, Section ? T
Town of ~o St. Croix County,
SubdiviaionA~'n~a- Lot number!
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.. Prooer maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a l'icens'ed' 's'e t'ic tank um er. What you put into
the system can affect the--function of tine septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents'-mn be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whic 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 'mss-t'ems 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)•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. 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 Depart-
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.
~J
C_ 1 LC
SIGNE
I
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016.
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND
P.O. BOX UMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53969
H
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNS"H~P/fi41~PH82 AtOTY: LOT NO.: BLK. NO.: BDIVISION NAME•
N1- 1/ NE 1/ zn /T-L9 N/R/Q'BJ(or W f~u 36 - PQr4ealjo GTs
g_WyJNTY: OWNER'S/BUYER'S NAME: MAILING AD RESS:
~rC~2o ~x ~A I UER l4~ > l
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: TESTS:
Residence UA.A< XNew ❑Replace T/75) 8 C 9/
-Sows &'o I< 58 0
RATING: S= Site suitable for system U= Site unsuitable for system So wg - Jig- SATI*E OUND: COZ STI❑U MX S ❑U IN GM S ROUND-PEJRESSUU RE: SZEM-IN❑-FILLHO❑LDING
TAJNK: RECO►yJ{VIEn~~ NVEN If Percolation Tests are NOT required DESIGN RATE: Csted a i
~ If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Co~S Floodplain, indicate Floodplain elevation: Nl~
car PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH MR ELEVATION OBSERVED EST. I HE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 1 4z 96.67 lea > 9.4Z 11 "BLCM Z1'164 69 *8e.4 rl'iS-rG
B- Z Q.So 9639 p 9-so 20 $Lers 20'89,4 L ? " N MS f4 R
B- 3 9 .Sb qt ,26 d C .s a xo `B«as r seN L 7 7"84N r►,s 44 K
B- 4 9.s0 96./9 > 4so Zz' ~Z~ ,,L o" $ >NS44
B- S Q,~3 ~S tS r~ > 9:83 Itoti.c,s Zo"BeuL 26'Acat1414sif"R u"SeftMS
B-
EL PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IAIfJ1lV AFTERS ELLING INTERVAL-MIN. PERIOD 1 PE PERIOD RI D 2 PER INCH
P- A-70 c 94 6 3 Z >Z >2 0<
P_ 7- 4A6 Name %Ao Z >Z >2 <3
P w o •ZO > >Z >2
P-
P- EY/dTl iv dT Cwt
P_ I
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 42.oa
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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 WER COMPLETED ON:
ADDRESS: CERTIFICATION NUMB R: PHONE NU BER(optional):
fs-6'&N 91 das(SKJ I S o 3
CST SI TURE:
RA Nk~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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