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SANITARY PERMIT APPLICATION
DL MR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
5X Gro~X
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 14- ?Q 14
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 ROPER L ATION
' %,S T N,R (orfq)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
d5- - -
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE 1 i NEARES~ O D~
❑ Public IN~ i 41 or 2 Fam. Dwelling-# of bedrooms EL TAX NUMB ( )
III. BUILDING USE: (If building type is public, check all that apply)
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
40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.2 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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
130 Seepage Pit Pressure 430 Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~~yy~ ELEVATION
SO® /Wr Feet Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank F1 p
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/MPRSW No.: Business Phone Number: 4a4no.~, 3/ 2! L;w 7
PI ber's Address (Street, City, State, Zip Code): 0.1 -
I
Dm/
10477 isL-A~Ae IX. C LINTY/DEPART ENT USE ONLY
❑ Disapproved it ry Permit Fee (Includes Groundwater Date Issue Issuing A it Signature %Ny Stamps
Approved ❑ Owner Given Initial Surcharge Fee)
Q
Adverse Determin Lion
X. CONDITIONS OF APPROVAL/REASONS F 6R DISAPPROVAL:
1 I
398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
APPLICATION FOR SANITARY PERMIT
STC-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 ~DARL(~-/vC (S
Location of Property (,J ,'14, Section , T_~ N-R~ W
~v w y .vw yy /6
Township mQ_>ZSP
Mailing Address A Sf~
0. W 9-
Address of Site SA M c
Subdivision Name
,Z
/ D q
Lot Number ,;2 CS U 0'L J`~ ( I o~ 1
Previous Owner of Property ~d V. seA (A C,HTIV61?-
Total Size of Parcel 3,o i A ~N~/4d~Ky -7-:5-0 A
Date Parcel was Created / / 9 6 Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume _ wand Page Number t:c! s recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and page number, and 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) ceAti,by that att statement.6 on this 6onm ane tnue to the best o6 my (oun)
knowledge; that 1 (we) am (ace) the owner (s) o6 the pro peaty deb n i,bed in this
injo,%mati,on 6onm, by vi tue ob a wavcanty deed neconded in the 046ice ob the
County Register o6 Deeds ab Document No. '3777?-6 ; and that I (We) pees entt y
own the pnopob ed site jot the sewage dis pas system (on I (we) have obtained an
easement, to nun with the above de6nibed pnopenty, 4on the conbtnuction o6 said
system, and the same has been duty neconded in the 046ice o4 the County Reg"ten o6
Deeds, a6 Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
/9 0 -Z,
DATE SIGNED DATE SIGNED
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1 4's TOWNSHIP
SECTION- T Z N-R~W
ADDRESS;2-&j-,e ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f
r pQ ~ ~m ~/r
I~ I
t~
4/0 5f INDICATE NORTH ARROW
BENCHMARK:Elevation and description: ,P o ~~efr.~~~X
Alternate benchmark
SEPTIC TANK:Manufacturer: sec 1~S Liquid Cap.
Rings used:0 Manhole cover elev:~° / Final grade elev:/ o o2 2
Tank inlet elev.: 100 ZTank outlet elev.: /~of
No. of feet from nearest road:Front , Side, Rear Ft. LV
From nearest prop. line:Front , Side , Rear Ft.~ /fib
i
No. of feet from: Well Building: 1,4"
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
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: /A r Length -3 Number of Lines: Area Built
_6
Exist. Grade Elev. Proposed Final Grade Elev. 7, ys'
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from well: No. feet from building 4/5' r
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:,
LICENSE NUMBER:
6/90:cj '
13 3
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BDIV SI N
LABOR & HUMAN ILLATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
P.O. BOX 7939
MADISON, WI 53707 State Plan I.D. Number:
NW%,NW%, Sec. 16,T31-R19 El (Ii assigned)
CONVENTIONAL ❑ ALTERATIVE
Town of Somerset ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
4 O RA IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Charles Annis 2199 40th St., Somerset Wi Y a,~-71
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of PI tuber: MP/MPRSW No.: County: Sanitary Permit Number:
Byron Bird Jr. 13318 St. Croix 149014
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKNG COVER
PROVIDED: PROVIDED:
ti• /r-') C z x 7 ° ® YES ❑ NO ❑ YES B NO
BED 'ING: VENT DIA.: VENT MAIL.; HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES O q 1- ❑ YES NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MO[EL: PUMP/SIPHON MANUFACTURER: WARNING LABEL L CKING OVER
❑ YES E] NO 101 YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROL P AT L: NUMBER OF PROPERTY WELL: BUILDING: AER T TOT RESH INLE
(DIFFERENCE BETWEEN FEET FROM LINE:
PUMP ON AND OFF ❑ ES NEAREST ~
SOIL ABSORPTION SYSTEM. Check the soil moisture at the de of OW 9 FORCE LENGTH: DIAMETER: MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction sha ea un it MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DI . PIPE SPACING: COVER INSIDE DIA.: ;WL LIQUID
BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DI TR. NUMER OF PROPERTY BUILDING: VENT TO FRESH
BELOW eIPES: ABOVE GOV R: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR I LET:
'7 16
i'G S 9T t NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARFSEEDEjD:ES OBSERVATION WELLS;
T❑ YES ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: MULCHED:
CENTER: I EDGES:
❑ YES ❑ NO ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
COVER:
WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.:
ELEVATION AND
INFORMATION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY:
APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: C", ` : 7 FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
i f
Retain in county file for audit.
Sketch System on TIT
Reverse Side. r IGNAT RE:
"710 (R. 06/88) ~1 VT-~
DESCRIPTION
A parcel of land located in the SIV.l./4 of the SIV114 of Section 9 and the
NW1/4 of the NIVi/4 of Section 16, T31N, R191V, Town of Somerset, St. Croix
County, Wisconsin, described as follows: Beginning at the SW corner of said
Section 9; thence NO°53'58 (True Bearing) 141.30' along the West line of
said SIVl/4 of the SIV114 of Section 9; thence N89°35'27"E 355.05'; thence
S1°06'26"E 365.00'; thence S89°35'27"1V 360.001; thence Nl°06'26"IV ?23.72'
along the West line of said NW1/4 of the NW1/4 of Section 16 to the Uoint
of beginning. `
Subject to cascmonts of record and existing town road right-of-way.
This parcel contains 3.01 Acres being 131,040 Square Feet including town
road right-of-way or 2.50 Acres being 108,960 Square Feet excluding towrn
road right-of-way.
I certify that the above description and map are correct and that I have
fully complied ,~-ith the provisions of Section 236.34 of the Wisconsin
Statutes and Section 5.4.2 of the St. Croix County Zoning Ordinance.
Date: April 19, 1982.
1Val.ter Crego y '%1224 Job No. 82-1343
,meta*.ecrs,as.~, Ogden Engineering Co.
0/V 123 E. Elm Street
s
(RIVER 1~~- River Falls, Wisconsin 54022
WALT ED EGORY
• 5-1224 t
w J
i FALLS,
L
SUR
,',P~ ~oeoise~ •S'~~
I hereby certify that this map has been approved by the Town Board.
Date
771-
Milton M il~ke, Town Chra ' hna!n
Bryan.. R d` _
pe p~
Ed Schachtner, Supervisor
Volume 5 Page 1219
I
II
~P ~
FORM NO. 985•A q j6e't,
S
2
10
Vow*
CERTIFIED SURVEY MAP LOCATED IN THE SW1 14 OF THE SW1 14 OF SECTION 9 AND THE NW1 /4 OF THE NW1 /4 OF
SECTION 16, T31N, R19W
OWNER & SUBDIVIDER
NEST 1/4 CORNER FRED V. SCHAC HTNER
SECTION 9, R.R.#1, BOX 97A
T31N, 8194,' 1 SOMERSET, WI. 54025
I I
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SCALE IN FEET
M
0' 100, 2 00'
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1 I
1 3 3' 33'
I
1 i NW CORNER OF THE SW1 /4 OF
THE SW1 /4 SECTION 9,T31N, R191,7
ul I ? < I
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C I
x ? SW1 /4 - SW1 /4
o I u: j I
I 0 I SECTION 9
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U N P L A T T E D L A N D S
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TRUE o 6I6~
BEARING C) o
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I N89035'27"E 355.05'
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C) 4- 1 57 13, 1 7 8. 4 3' 21 9. 49'
° I 2 97. 92'
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I I c "I LOT 2
1 W' o _rd i
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POINT OF z~ I Ln- 1r N88°19'52"E
I o ~ of
BEGINNING 60
¢ I I I
SW CORNER JI
SECTION 9 0 I
i of
T31N, R19VJ aI IT
wl 1 I _ 131,040 Sc Ft. Total. wi l
o r i - Z 3. 01 Acres l Total. ~Z" )-I
~-I z I N I J 108,960 Sq. Ft. ercludina Lni
I N N road. - o t--I of
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2 U)
QI I y 1 _ Q 2.50 Acres excludina road. ¢I zl
~i ° I I I, J Lr' -jI ¢I
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LEGEND zl J~ i 0 Is F- -zl t
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COUNTY SECTION Z) U) a~ I z iz
MONUMENT, FOUND. 63.42' 1 296.5?'
1•x24" IRON PIPE, k E1G(iING I i S89035'27"'ei 3G0'
1.6"r/LINEAL FOOT, SET. 1 I J
<
I < 1 ~ C.J.M. - V. 3, I'q 821 1
EXISTING 1" IRON PIPE.
~.M. CERTIFIED SURVEY NIAP. I 1- z l Q LOT 1 I
~r? f r
I u) I w NW1 /4 - W.11/4
I w 1- I SECTION 16 1
i
66' M AY 1 8 1932
I
Volume 5 Page 1219 &T• 04iK covNry
CC UPy:Ii'ty^v. P>k.5 PLA'4:-:Kd
This instrument drafted by Douglas J. X'70h! ~x, zo;,~ya eanvvnc~
r,
z
En
H
a
ST C- 105 a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
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H
OWNER/BUYER AIJ
J, f t
ROUTE/BOX NUMBER I Fire Number
CITY/STATE ZIP~Z CJZ
PROPERTY LOCATION:, w34, Section, T ) N, R / W,
Town of .9a ~~-PON, S-e.+ , St. Croix County,
Subdivision C5K S109. 101 Lot number o2
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sYsts of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you pit into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master 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
H
three year expiration. H
E
z
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- 'd
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.
S I G N E
DATE Z
St. Croix County Zoning Office
P. 0. Box 98'
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
xOIL,. BORINGS AND SAFETY & BUILDINGS
~7 DIVISION
ABOR - - PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON WI 53707
LOCA ION: SECTION: TOWN~SH P/ ALI Y: r OT NO.:BLK SUBDIVI ON NAME:
~ , / IT- N/R 9 (or) W - s ~
COUNTY:' WNER'S BU ER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
S S:
F Residence ]NO. BEDRMS.: 1COMMERCIAL DESCRIPTION:
New ❑Replace
NS: I PERCOLATION 1-3 1111-4 1 1 RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (Optional)
IM S ❑U ❑ S ❑U IS ❑U ❑ S NU ❑ S ®U
If Percolation Tests are NOT required DESIGN RATE: E If any portion of the lot is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
7ROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- > 13-
U ?
'
B_
n
/ s<
13-
B-
S-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P RIO 1 PERI D2 PERIOD PERINCH
5 /
P
O P- r9 -.41Z 41-Z Y,/-
lid r,
P
LP
T<~C vc - /D
PL N VIEW: 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 slop.
SYSTEM ELEVATION
3 {
I r &
a ,
® r- N
TN
I S b ~ ~ I
.C{ Jµ
410014
{ P3 _
n S
a
}
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME 1 int : TESTS WERE COMPLETED ON:
AD ~JJ CERTIFICATION NUM ER: PHONE NUMBER optional):
CS TU i
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81)
OIL - '~Yf& BtJ! tRttdGS
DtVISION
T' V 11 "a S AN
-.a P.O. BOX "69
_ 5. OLATf V 'STS (115)
OP19". MADISION, Wt 53.707
CT H P Y T 1.7 : SU Dlt4 NA Es
or)
UNTY: BU .E` NAME: LI NU AD R SS:
.44
< DATES OBSERVATIONS MAP.
, i. NO. BE Q M A E TI O
iden ~Nevv F-1 Replace.
RATIN. i S~-Site suitable for system U= Site unsuitable for system
STEM:f i `
❑ SG®U • RECOMMENDEDYS
plyV SENT❑U • MRS: ~U IN~GROUN ~U . ~ S[IS TEM-IN- U FILLIHOLDIN
I I
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tot is in the'
under s,H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevations
ROFILE DESCRIPTIONS
BORING TOTAL P H R UNDWATER INCH S CHARACTER OF 501E WITH THICKNESS;. COLOR TEXTURE , AN DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. ES TO BEDROCK IF OBSERVED (SEE ABBRV.'ON BACK.)
B- )
B-
t
B_
PERCOLATION TESTS
-T-ERTF D TH WATER IN HOLE TEST TIME DROP N WATER..LEVEL-t CH S RA MI UTE
NUMBER INCHES AFTER SWELLING INTERVAL-MIN." I PER I PERIOD3 PER INCH
P-
P
c ,
P-
P-.
P
P
PL N VIEW: Show locations of percolation tests, soil borings and thedimensions 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 slop.
SYSTEM ELEVATION
e. ~ ~ f NTH
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin I
Adrnimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (pr{nt : / TESTS WERE COMPLETED ON:
Jf _ / _
Dp CERTIFICATION NUMBER: HONE NUMBER optional :
CS3,9MNA~TU Ey
l
DISTRIBUTION: Original-Lopal Authority, 2nd :page-Bureau of Plumbing, 3rd page-Property'Owner, 4th page-Soil Tester.
5 DILHRSB6SM!5IN,03/81)
PLOT PLAN
PROJECT C 4P-/e5 ADDRESS :P/ff o ~/f oina~se~Lc~i~S~foaS
le7AI4 W,0 114/S16 /T F/ N/R/y W TOWN aver e COUNTY
MPRS B`ron Bird Jr. l~AT o
y 3318 E
BEDROOM CLASS PERC L CONVENTIONALXIN-GROUND SSURE
CONVENTIONAL LIFT MOUND_ HOLDING TANK
SEPTIC TANK SIZE loo ® LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA ~L PERC RATE r• t~, BED SIZE 1a s
► Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
H. R. P. A!~ .Low.-~ -/-/o "or tea'
0 Borehole Well Scale = Feet
0 Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING
. ~ 2"
12" 3' 4 6' O 3'
1 6" Sewer Rock
1.2'
13~'~h
®r~
~ B.hl
00#
5
r
r