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Parcel 032-2068-95-000 04/30/2007 03:53 PM
PAGE 1 OF 1
Alt. Parcel 12.30.20.767F 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - KUBIK, VERNA M
VERNA M KUBIK C - BAILEY, VIRGINIA M
VIRGINIA M BAILEY
274 ANDERSEN SCOUT CAMP TRL
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 274 ANDERSEN SCOUT CAMP TRL
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE
SEC 12 T30N R20W 2A IN SW SE COM S1/4 Block/Condo Bldg:
COR SEC 12, TH E 1027.75' TH N 385.5',
TH E 226' TH S 385.5', TH W 226' TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
12-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/25/2005 810315 2915/372 WD
07/23/1997 776/94
07/23/1997 504/87
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/09/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 32,000 177,000 209,000 NO
Totals for 2007:
General Property 2.000 32,000 177,000 209,000
Woodland 0.000 0 0
Totals for 2006:
General Property 2.000 32,000 177,000 209,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 117
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP a ~eSGf
SECTION ____2_v?- T_N-RW
ADDRESS ,,2' S 7i. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
UJob,
x~
~y
A
z2 0
i
3o
Q INDICATE NORTH ARROW
BENCHMARK:Elevation and description: ,u~.~- ddeo~
Alternate benchmark
SEPTIC TANK: Manuf acturer : ~r 5 er Liquid Cap. 0 o~
rRings used:'i~Manhole cover elev: , -045 I-7 inal grade elev: /OG• /S
Wank inlet elev.: /9/, Tank outlet elev.: fD / 3~
No. of feet from nearest road:Front--X, Side , Rear Ft._,,//40_
From nearest prop. line:Front-"91, Side , Rear Ft.
No. of feet from: Well __240 , Building: 7,3 /
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
II ~I
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:-/.I" Length Number of Lines: Area Built
Exist. Grade Elev. ,/d{ 5- Proposed Final Grade Elev.
Fill depth to top of pipe: ~fa2
No. feet from nearest prop. line:Front---<, Side Rear Ft..C,;
No. feet f om well: No. feet from building
G4e / --V•O Gcl 97 q 9,7,
-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:
DATE : PLUMBER ON J
~ i
LICENSE NUMBER:
6/90:cj
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Duman Relations INSPECTION REPORT St. Croix
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION SE SW Sec. 12,T30-R19, Scout Cam Rd 149112
Permit Holder's Name: ❑ City ❑ Village [k Town of: State Plan ID No.:
Verna Kubik Somerset
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 1-
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man. r C'
Aeration NA Dist. Pipe -
Holding Bot. System
Final Grade
Manufacturer Demand , r r~ ~ 7" C
Model Number GPM
TDH Lift Friction m TDH Ft
oss ea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM 9~
BED/TRENCH Width ✓ Length NolOf Trer-hes PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS "S DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK CHAMBER
INFORMATION Type 0 o ~,1 / M I Number:
System: C_,:°y OR UNIT
DISTRIBUTION SYSTEM -
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length 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 Topsoil ❑ Yes ❑ No ❑ Ye o
COMMENTS: (Include code discrepancies, persons present, etc.)
o'h C~J~t~!L7Nt[/ ll. G1_d ST oL,c:~f C~z.i-~.tCl;, ~o i~c
r
C' ~J C-Q S L ~ ~ Z
Plan revision required? ❑ Yes No
Use other side for additional information. 141 O k SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
~ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
51, Gy- D
>c.
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8'/z x 11 inches in size. Check if`revision previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER WNER t PROPERTY LOCATION
y ,6/ S T QN, R E or
PROPERTY OWNER'S MAILIN% ADDRESS LOT # BLOCK
- -9 -7 a le~ ~ ~ d4l
CI , ST TE ZIP ODE PHONE NUMBER SUBDIVISION NAMgR CSM NUMBER
d r' 6
Flo ]__I
I1. TYPE OF BUILDING: (Check one) CITY NEAREST R D
❑ State Owned VILLAGE y e GfXc
Awwu On 4
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NU' R( ) 001
111. BUILDING USE: (If building type is public, check all that apply) 7t~~
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2.;2~eplacement . 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet
FR.
`7~ 9' L ~C7 Feet
VII. TANK CAPACITY Site
New ab. Fiber- Exper.
in allons Total of Pref
INFORMATION istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank X I T-1 F]
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 a (Print): Plum s ignature: (No Starrs) MP/MPRSW No.: Business Phone Number:
Plum be dre (S at, City, State p Code):
iJ
IX. CO NTY/DEPA TMENT US O Y
❑ Disapproved Sanitary Permit Fee (includes Groundwater ) Date Issued Issui Agent Signature (No Stamp
Xroved ❑ Owner Given Initial
App Adverse Determination S harge Fee
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 15R,J Q A.. I~U 8 1 Z
Location of property~~1/4 154-114, Section 1;2, , T 30 N-R A Q W
Township _ 5c If-R53E r
Mailing address a-;t -7 Z/ 5e. 6,v r Cam R(y
9a y I0 5 Z
Address of site S!~ 14
Subdivision name Lot no.
Other homes on property? yes )L., No
Previous owner of property Q e y t A 4 ZJ S T
Total size of parcel ,g G 14-"
Date parcel was created v' l97 0 -
Are all corners and lot lines identifiable? x' Yes No
Is this property being developed for (spec house)? Yes ~C No
Volume6 0 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 ffice 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 applicant C 7applicant
LLB l
Date f Signature Date of Signature
j DOCUMENT NO. STATE BAR OF WISCONSIN- FORM 2
WARRANTY DEED
A w THIS SPACE RESERVED FOR RECORDING DATA
BY THIS DEED, David A. Hallquist and REGISTERS OFFICE
Patricia He Hallquist, Husband and ST. CROIX CO., WIS.
wife Recd for Record this--9-Q.
Grantor conveys and warrants to Donald • Kubik an day of_ October __A.D.19_Z3 !
Verna Kubik, us an an t__9_z~t M.
O,
wile
tegister of ~-Dee(rq
Grantee 8
for a valuable consideration RETURN TO
S 43m500.00
the following described real estate in St. Croix County, State of Wisconsin:
f
Tax Key #
This is homestead property.
A parcel of land located in the 34 of the SEJ of Section 12, T30N., R20W,, Town of
Somerset, St. Croix Countyp Wisconsin described as followss Commencing at the S
corner of said Section 12, thence East.9 assumed bearing, 1027.75 fte along the
South line of said SE I to the point of beginnings thence N 0 degrees 24 minutes E
385.5 ft. thence East 226.0 feet, thence South 0 degrees 24 minutes W 38505 feet$
thence West 226.0 feet to the point of beginning. Except a town road easement
across the South 23 feet, more or less. County of Saint Croix, State of Wisconsin.
E
TRA SFER
3. 0
FEF -
Exception to warranties:
j
S . {
'~tF
.5 tr-► ' (~a7t S Ly 4th 'ember
Executed at phis day of_ 1933L.
SIGNED AND SEALED IN PRESENCE OF Z { ~f " (SEAL)
David A. Hall uis 1
tr i (1 (SEAL) I
Patricia H. HallquiI
(SEAL)
(SEAL)
ii
j'.
~j
i'
Signatures of
~I
iI
authenticated this day of 19_. ii
I
Title: Member State Bar of Wisconsin or Other Party
Authorized under Sec. 706.06 viz.
STATE OF WISCONSIN
St. Croix } S$
County.
Personally came before me, this 4th ✓ day of Se t r 193
the above named David A. Hallquist and Patricia H• Hallquist a
I
to me known to be the person 8 who executed the fo'\'wtr, ment and a 6w edg d then ee.f
' ~J'~ /10
" Kendall B. Priester
This instrument was drafted by VVV~ X„w •
a Am
Thos St Croix
. J. O'Brien 9.~ Notary Public r County, Wis.
~ p = sz Et8 .r
j The use of witnesses is optional. My Commission (Expires) (Is)
Names of persons signing in any capacity should be typed of 'printed belov%Aheir s' atureS.
see, ~~„F M.GMi11.rCompairy~
i . ra:.
41 WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2 1971 $7
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER L I
ADDRESS: 277`/ SCOUT rAM !nc FIRE NO: 7
LOCATION : $G) 1/4, 5Z- 1/4, SEC. T__5(7 N-R ;R O W,
TOWN OF: S ST. CROIX COUNTY
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: !/Jla ZY2 2~Gt.Lc A
DATE:
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(ILH 83.09(1) & Chapter 145)
LOCATION SECTIO~j30N/R ( A WN IP`/MUNICIPALCT LO` NO.:BLK.NNo.: SUBDIVISION NAME: 11 -
COUNT/Y: M IN :1
Goa,!
USE DATES OBSERVATIONS MADE
NO BEDRMS.: COMMERCIAL DESCRIPTION: ROFI DESCRIPTIONS: AT N TESTS:
I,[~Residence~ ~ ❑New Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTE~`M-IN-FILLHOLDIING TANK: RECOMMENDED SYSTEM: (optional)
S EIU E-S EA S EN ❑ J S V
DESI
uired If any portion of the tested area is in the
If Percolation Tests are NOT re( GN RATE:
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: Q
6 PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
x-57
ay~c a~!-~~~~ sy~
13- L4 lVe9 113-
B-PERCOLATION TESTS
G
F EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
MBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH
P
P
P
P•
P- _
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation rderence points and show their location on the plot plan. Show the su face levation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 9~'v
i
p ~I'fJ /1 0 c.. l o.o/
mw prv
3 ,6~ ~o st - i~ ~
T N
O
"R 3 '
@I~ Sys Act i
► c1(0 6
'co``f GN
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord th 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 (pri t): TESTS WERE COMPLETED ON:
CERTIFICATION UM ER PH NE NUMBER (optional):
~
ADD ~ ~ ~
CST SIGNA R
a
p., DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
PLOT PLAN
PROJECT ADDRESS co u a~ ,
xi/4 ~1/4/S/~/T7d N/ W TOWN CQUNTY Byron Bird Jr. 3;318 DATE -
BEDROOM CLASS PERC ONVENTIONALZIN-GUND PRESSURE
CONVENTIONAL LIFT_ MOlN' HOLDING TANK
SEPTIC TANK SIZE ;%,.,e/LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
► Benchmark V.R.P. Assur6 loo'
Location of Benchmark
* H.R.P.
O.Borehole Q Well Scale Feet
0 Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING
12' 3' 4 6' 0 3' 3' 0 3'
I 16' Sewer Rock
i 12' 18'
Uwly
~s
gel
~1Go~, 7~ Gu ~../J ~Ccl
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
n
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the / ~e/-"/-? Gc 6,'~' residence located at:
1/4, 1/4, Sec. /--Z , T_Z~LN, RW, Town of
Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly. c~
Last time serviced 7
Did flow back occur from absorption system? Yes,,K_No (if no, skip
next line)
Approximate volume or length of time: 1~0 gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacurer (if known) : cc>C~S
Age of Tank (if known) :
(Signatu ( ame) Please Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name Signature MP/MPRS
5/88
1
EPUS_ JT OF REP RT ON SOIL B INGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS
(ILH 83.0911) & Chapter 145)
LOCATION: SECTION : WN IP/MUNICIPALITY: LOT~NO.:BLK^NO.: SUBDIVISION NAME:
~~/~.s~~%a I oN/ E( P H e
COUNTY: MAILING ADDRESS:
Grgr (~er ~e~.~~~ Wca 4 fey G61i i~ V-0
USE DATES OBSERVATIONS MADE to
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER O ATION TESTS:
x❑ Ne Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑u 9S ❑U YS oU o s E ]S u
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: Floodplain, indicate Floodplain elevation: ~Q
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK:) y~
B- ~ ~ ~ ~ o ~~~s $ 3a ~ -gym ~s~►N
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER JONEW AFTER SWELLING INTERVAL-MIN. -PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- S O p?~2
P_ a J
P r
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the s5 face . levation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
o°crc
.12$ N
5-
0.5" r
A►
~ v Esc z
` .3
CO P
?s"
C6 /92 ~4'
Lt G~
I, th u ~gr y~, hereby 'f at the soil tests reported on this form were made by me in accord ,,Rh the procOC~edures and m ods specified in the Wisconsin
Admim 'L trg rani t fit! a data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME( pri t): TESTS WERE COMPLETED ON:
W h j-, a -Z! -Z?Z
ADD CERTIFICATION NUM ER: PH NE NUMBER (optional):
CST SIGNA R :
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - O'✓ER -
Wisconsin Department of Health and Social Services
PtMK#67 10/69 Division of Health
PERMIT APPLICATION
for eu b i'L bo_n VVI -7
~ V'1 C1 !PRIVATE DOMESTIC SEWAGE SYSTEMS 41 v u
~~-3U Zy~S~ ~ - z3
A. OWNER OF PROPERTY J~~ C l (t f~ TYPE OR USE BLACK INK
Name rt Address (Street, C)ty, Zip Code)
County
B. LOCATION OF PROPERTY'WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED
Check One: L21~
CITY VILLAGE LEGAL DESCRIPTION:
s~
=,TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? L --YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY C t 4 Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NLMBER OF TANKS TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence I- Commercial Industrial other
Specify
Number of Persons to be Accommodated 4-1 Number of Bedrooms
F. APieLIANCES, ETCs Food Waste Grinder DYES NO Automatic Clothes Washer /-YES NO
Dishwasher YES NO Automatic Potato Peeler YES' t-NQ
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Beds Length Width Depth Tile Size No. Lines
1 Seepage Pits Inside diameter_ Liquid Depth
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level -_,vel Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overni ht 11n, Minutes Last Period Last Period Period One Inch
Example
IP- 0 36" To Soil 10" Clay 261, 25 es or no 30 1/2 1/2 1/2 60
LIZ 3
3 3 2 i
7,2 10
3
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
omputs •ize of absorption area in sword with H 62.20 Wis. Administrative Code.
S 0 I L B 0 R I N G S- Minimum 36" Bslow Pro osad Absorption System
oring Total Depth Depth to Ground Water Death to Bedrock
umber Inches Observed Estimated Observed Estimated Charaoter of Soil with Thickness in Inches
xampls
- 0 721f 72" Black To Soil 12". Clay 18"• Sand'181% Gravel 24"
k (4 /1 Of
ff.. it n f I S0
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
j
Is the undersio ed, hereby certify that the percolation tests reported on this form were made by me
or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief.
NAME ./PLC. 1, 2- / L-t///"' I TITLE CL' ~Z
~ (Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE No.
ADDRESS
✓
SIGNATURE DATE
MASTER PLUI' ER MAKING APPLICATION
Signature: ell' 11 License Numbers ME -tl - MP RSW /l J'
--r
(To be Completed by Issuing Agent)
Date of Application /`l /Z Fee Paid $ U ~J
Permit Issued ~(da e) _02Permit Number
Agent (name) KIi.' f.~~jJ 1'. 1i~~ C•~Z~ For. li~1fJ
Town, Village, City; County, etc.
(Specify)
Notes The application cannot be considered for filing until all of the above questions are answered
and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the
Permit (yellow copy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
i
Do not write in space below - FOR DEPARTMENT USE ONLY
DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) (see Corres.
FEE RECEIVED ✓ VALID. NO. PERMIT NO.
Yes or No)
REVIEWED BY APPROVED DATE
(Initials) (Yes or No)
COMMENTS: