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HomeMy WebLinkAbout036-1043-50-200 -0 0 3 0 N O Q. O r~ Q rn ~ N = N U O O co O N c c N 0 CO LL a aO q Zt a3 O e o. O N C O (n , S m W N (n rn w 3mo O O i c z N •3 m - m r U. o ? oo. ' "0 Nom.- j a QUO) M z E U z ~ ~ v a m w W cn C O c -O co O Z ? c 0 c y 16 cUi 'Z d c to F- r m z C E y~~] f~ j ~ N M _~V N O I CL N N Q 'n (D 1•IJ 0 a L O C ' O O O O N Q tF Z co z o N _ z O d N M E tv £ t N ( > m U y _ Cl c0 CL C L C 3 2 o °o Z M> O f' N O O a s 0 0 0 Z° •►.•i m ¢'aaa a = O 7 O N N y to J V co ~2 N 00 E o .V 5 O ° O i~ N .O. C Frw o ? Q Y ml N of C Q N N O O N y N C Q C c O C N Z O 3 N V N N N O C C U p~ ~ N Y Y C 'O a!,C j' O r` _ N N O N O _ O y w M M 2 -0 CO Z' Z. C N C C N CD • 7~ O M f0 0 O q 0 m m M., it O (n r O z y (n O C{S i w t d W a E L c c j i n cn O 3 v n 3 3 r~l E m a m • d m m 1 3 p 4i ~ O a~ • s o m a o CO c o n°> 4 CL 0-0 CD 0 CD CD M CD ? co 3 0 O 7_ N iu t CD n ' 7 V O O a 0 7 N O N to o O y c N (D M 'p C z D CD c D a CD _ z O o 0 'o p- D o r, CO) c ? 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CROIX COUNTY, WISCONSIN SUBDIVISION 44- LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - v ,o tf a INDIC TE NORTH ARROW l r BENCHMARK: Elevation and description: 4~ I I ~ Co Y ae I / 60 Alternate benchmark SEPTIC TANK:Manufacturer:,rs Liquid Cap. /&O-n Rings used:_3_Manhole cover elev: ?$,7SFinal grade elev: Tank inlet elev.: r9 Tank outlet elev.: 9 No. of feet from nearest road:Front, Side , Rear Ft. From nearest prop. line:Front Side Rear Ft. No. of feet from: Well 7C/ Building: y (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE w 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: Ca Length !O ` Number of Lines: a Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: .39 No. feet from nearest prop. line:Front Side, Rear Ft./°7S No. feet from well: C13 No. feet from building S/ 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:- s- PLUMBER ON JOB : + LICENSE NUMBER: 6/90:cj Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human,Relations INSPECTION REPORT St. Croix Saf wy and B~Oclings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATIONSE4,SW4,Sec. 18,T31-R17,120th 149217 Permit Holder's Name: ❑ City ❑ Village 121 Town of: State Plan ID No.: Dennis Johnson Stanton CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /00 1272A 036-1 043-50 9 TANK INFORMATION ELEVATION DATA 9/ the TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 60 Benchmark /00, Dosing Aeration Bldg. Sewer Holding St/Ht Inlet 9.5-7 q,`13 TANK SETBACK INFORMATION St/ Ht Outlet /p, Dd- TANK TO P/ L WELL. BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe lo, q 3. q Holding Bot. System 013. PUMP/ SIPHON INFORMATION Final Grade . a7 c1 033 Manufacturer Demander 7 J Model Number GPM TDH Lift Friction System TDH Ft mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No_ Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 6 v DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM INFORMATION Type 0 CHAMBER Model Number: System: -~c8 S S g'~ 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 ax Depth Over xx Depth Of 7 xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter Bed /Trench Edges Topsoil C] Yes 11 No E] Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) c 7 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date nspector's Signature Cert. No. MEMO ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: • SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code !uNTY. STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than I 7 c5 / 8% x 11 inches in size. 1:1 check If revision to prey ous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION SA!~ Y4.Ta '/a, S/,8 T, 3 , N, R 7 E (or) W PROP TY OWNER'S MAILING ADDRESS LOT # BLOCK # lJ' - CI , STAT ZIP CO E PHONE NUMBER SUBDIVISION Z N E OR CSM NUMBER 'AJ '1J-eAA1D 'ALL - 1( 70 & II. TYPE OF BUILDING: (Check one) El State Owned VILLLLAGE : NEAREST ROAD 4 FL N OF: ❑ Public 1 1 or 2 Fam. Dwelling-# of bedrooms PARGEL AX NUMBER(S) 4 111. BUILDING USE: (If building type is public, check all that apply) p?zu g w 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 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. X New 2. ❑ Replacement 3.E1 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 ® 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 4. 9 Feet 97 Feet VII. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks . Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber. VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of a nsite sewage system shown on the attached plans. Plu i7same (Print): Plu is Sign re: mps) MP/MPRSW No.: Business Phone Number: Plu7?, s Addre (Street, City, State, Zip C de): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Iss ng Agent Signature No Stamps) Approved ❑ Owner Given initial Surcharge Fee) . Q Adverse Determination / r4o 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 san[tary.Rermit is valid for two (2) years. 2. YoursaOary'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 (SBD 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, pump/siphon and holding tanks for this system. 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'h 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 tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water riainsiwater service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump 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 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) II 1 a fi APPLICATIONFOR SANITARY PERMIT ETC - 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 got :esalt by evner/contcactor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the approprlate deed recording. - - - - - - - - - - - - - - - - - - - - - - • • Owner of property _ rL/r'i✓A/is .J~n.S/.l-~ms,/ Location of property ~/4 „-,<-Lj i/l, Section . fQ %Z( -MU.Z_y Township Mailing address .1 7 • Address of alts s V Subdivision na" Lot number Previous owner of property OC11,4- Total else of parcel Date parcel was created Are all corners and lot lines ldentlflablet_Yes o is this property being developed for resale tepee house)? as 0 Vol*" and Page Number /0 5 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THS FOLLOWINCs A WARRAXTY DRID which Includes a DOCUMI<NT NUM8SR, VOLUMR AND PAO>Z NIMAIme and the REAL OF THR REOIBTER OF DESD9. In addition, a certified survey, it available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a Ceitlfled survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(Vs) certlfy that all statements on this form are true to the best of my (out) knowledge; that I (we) am (are) the owner(s) of the property described in this Intotmation [arm, by virtue of a warranty deed recorded In the office of the County Register of Deeds as Document Ho. 7-1'1_3 5 9 1 and that t (we) presently own the proposed alto for the sewage disposal system (at I (we) have obtained an easement, to tun with the above described property, for the cons ctlen of said system, and the same has been duly recorded In the office S t e ounty Reglstar Deeds, 89 Document No. s g atute of Owner Signature of co-owner itf Applicable) ate"ot Signature Date of Signature ~A..lIIR~~ M ;,lj, ~tats~, + ~ (;sgtee, .xts ;....A.:..: . r4ft AD Mtn GMMbr, ht 1 "hU6b 4MILMti00...... { ~sTUOar+o~-- lssenJW uhl atop is . _ ..s~t r _.T.4 #.X........ r Tax I= No:- tt~ of Secdon fir Town,04 31' I. t~ a# ie Soudleed corm w of r f - . , , f~~c fd 1~ ~kn is s point 7S rods WeeC.ed'dMt- faCA of bepttAitt; iMp in tNtttitdeetias of that land contract bM I $ew a e" mpg & M the St czak c w Vatttit w 6M of Records on Nee '.lr W. ' +I WOW 00 rstaditaa>t aad appatteaamw tbt waft itrir iMh A* so do* and free aad euw of ~ wvnka~ g`A .fig OrOaauces -and easements of record j iM*'d~ drs Mesa: y ^ *a" this day of ..:September. , 11►_d~YM s 1 ~r~ ' i►11~W'~#~DLltON Y~ k k.^ ~ Actclrowr.tcaoMRtr: r w.; . STATE OF WISCONSIN x S St.• Croix as 4* •t, 1!:__... p oodly case bef £j -------~ptdtl!l1~.._. r! Sp th.:lk# .fit..r wtscoristH . pMq""X -IM _ to aye known to be the pens CRAFT" SOMACHER • e Y' ::t~jireisii i~.!saMtirswt,:;#r~► i Aw yyp~Y gg ~ ~y Q DOCUMENT NO. J~STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA ~I WARRANTY DEED This Deed, made between --Eva_._Smith a./kJ_a-________-__•_•_•.-. j II EYa..A....Sm th3 single__1?erson,......... _ l Grantor, and.... Dennis A._ Johnson and Janice K._ Johnson......... j • ....husb.and..and_ wife, as___j_oint_ tenants., Grantee, Witnesseth, That the said Grantor, for a valuable consideration St Croix...-. RETURN TO conveys to Grantee the following described real estate in County, State of Wisconsin: I L._..._ Tax Parcel No---------------------------•------•- I Part of the Southeast 1/4 of the Southwest 1/4 of Section 18, Township 31 North, Range 17 West, described as follows: Commencing at the Southeast corner of the Southwest 1/4 of said Section 18; thence North on the quarter section line 60 rods; thence West 30 rods; thence Southwesterly near the center of the lake to a point 75 rods West of the place of beginning; thence East to the place of beginning. This warranty deed is given in satisfaction of that land contract between Grantor and Grantee dated August 31, 1981, and recorded in the St. Croix County Register of Deeds Office on September 2, 1981, in Volume 635 of Records on Page 58 as Document No. 373154. - E This is...n.9t....... homestead property. (is) (is not) i Together with all and singular the hereditaments and appurtenances thereunto belonging; And...... Grantor------- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal zoning ordinances and easements of record and will warrant and defend the /same. Dated this ~Sc? `f- day of September--------------------------- 19.91.. 6 f »'L.t.......' .............................(SEAL) ......•---....-•---....(SEAL) * Eva Smith "a/k/a (SEAL) (SEAL) * i AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN i ss. St. Croix County. -.da authenticated this ........day of 19 Persona y of lly came before me this SeP t emb e r 19... 9.1 the above named " Eva-. Smith ajk~a_ Eva A. Smith TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the fore oing instrument and acknowledge the salve. THIS INSTRUMENT WAS DRAFTED BY BAKKE, NORMAN, SCHUMA.CHER, II -•-.SKINNER WXjTR-' 9T-RAN•S S-:-C: N.ew-.-Ri_Chiaond.,...W1.... _5AD.17 Notary Public St..__"Croi•x------------ County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (}f not, state expiration are not necessary.) date: /-/V 19.J--T.) ++it -s of persons signing in any capacity should be typed or printed below their signatures. STEPHAME A DESINO No1 :PubClc-Statk!f STATE BAR OF WISCONSIN _ Grllw~ FORM No. I - 1982 Mock No. 13001 0 3 d r • SEPTIC TANK MAINTENANCE AGREVIENT St. Croix County LAN/\ OWNER/ BUYER Ja'_10:~d,.,_i w O ROUTE/BOX NUMBER Fire Numbert . to CITY/ STATE zJz_'1ae.4W L✓ 1 ZIP rt PROPERTY LOCATION:_ Section TAN, R_LZ_W, Town of gz l j St. Croix Coun y, Subdivision vx Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed •s'e t'ic tank pumper. What you put into the system can a ect t e function ot t e*septic tank as a treat- ment-stage in the waste disposal system. St. Croix Countyy residents may be eligible to recieve 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 'sys'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 f three year expiration. X. } 0- 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, asset by the Wisconsin Depart- w ment of Natural Resources. Certification form must b completed •d and returned to the St. Croix County Zoning Office wi hin 30 days of the three year expiration date. f, SIGN DATE- 5 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT,OF a7~ y REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR' AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: 4 SECTIO : N/R (or TOWNS IP/M IgtC!rAt!TY: OT O.:BLK. SUBDIV ION NAME: C. TY: O NER'S BUYE "AIC4.)S NAME: rzNG ADDRES . USE DATES OBSERVATIONS MADE Residence NO. BEDRMS.: COMM R A DES RIPTIO New ❑Replace PROFILE DESCRIPTIONS: PERCOLATION TESTS: RATING: S= Site suitable for system U- Site unsuitable for system G +7 7 :loptional) ST RNVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED yj' osOu ®SOu aSOu OS®u OS©u _,j,/ ~ If Percolation Tests are NOT require DESIGN RATE- 4 a P If any portion of the tested area is in the under s.H63.09(5)(b), indicate: X2b lFloodplain, indicate Floodplain elevation: it, Iv. PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GR UNDWATER-INCHES CHARACTER O IL WITH THICKNESS, LOR, -TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED S HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- } B- T B- 9'A - ; r B- B- 6-1 ~"W B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD l- PERIOD 3 P RI 2 PER INCH P- / C P. J - ~.5 S P- 9 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 surface elevation at all borings and the direction percent 01, of land slope. SYSTEM ELEVATION e° ~~~x , I \ V N I T , r t let 01 I i i I, the undersigned, hereby certify that the soil tests reported on this form were ade 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 c - eut to the best, y knowledge and belief. NAME prin TESTS WERE COMPLETED ON: A CERT FICATION NUMBER: PHONE NUMBER (optional): 41ot&4U C DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD -6395 To be a complete and accurate soil test, your report must include: 1. Complete legal, de'script ion; ..2, The use section.must clearly, indicate whether thi§`is a fesidence or commercial project; 3.~ MAXIMUM number of*bed rooms orn " or c-' lmercial use panned; - 4. Is this a new or replacement; system; 5. Complete. the suitabilit-r rating boxes.'A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet meX.4e used if desired; 8.. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, it appropriate; 10. If th infQrrnation (suldi as flood, plain, elevation) does riot apply, place N.A. in the apps otuiate box; 11. Sign t e form 4nd place your C&reht address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. 1 P ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols ' st Stone (ov(r 10") BR - Bedrock rob - Cobble (3 - 10") SS- Sandstone gr Gravel (under 3") LS - Linwstorie Sand r HGW - High Groundwater cisCoarse Sand"; ' s ° - Perc Petcolatiop Rate need s Medium Sand` 1N We li :-fs. Fine Sand Bldg Building Is Loamy Sande > Greater Than *sl Sandy Loam < Less Than *1 - Loam Bn BroNii *sil Silt Loam BI Black si Sill: Gy - Gray cl:- Clay Loam Y Ycliovv scl Sandy Clay LparnR - Red sicl Silty Clay Loam mot - Mottles sc - Sandy Clay vv? v"' i t I sic Siity'~Clay fff fewu, fine, faint t "c Clay cc - common, pi - Peat Inn) Many, rneciiurra m - Muck d distinct k h - prominent t, HWL - I-ligir watei levcl, Y Six general soil textures surface ti-uator for liquid,-yvaste disposal BM Be>i,(" it r"'1a,k VRP - Vertical ft~>ferrt ~,<< Ic;~,:t r ,i TO THE OWNER: This soil test report is the first steOln-securing a sanitary permit.. The county, or the Del)& une3nt in ay rei caest w-l ification of this soil test in the field prior t:o permit issuance. A complete set of phtns for ow pl;v mtt se,vage system and. a permit application must he subrnittecl to the appropriate local autlux ;r in o! dcr to ohrain a perrnit:.Ttie sanitary-,ptarrmif must he obtainer,! and posted prier to the start of <wy cunsiownon. I~ ~ I I I ' I I I I I f I i - I I ~ r- F- a I Sid, I - I I_ I : I I I - I I I ' ' I ' 1 I I_- I I II I i i { y 77 n I ~ I I ' I I I It i- ~ I- I' : ' I i I I I I { ~ _ i I ' 11 li ~ I I i' I I I I I - _ I I 'I I I I , I 1 J I I III `h•' `~TyI/"/l i I ' I I-. I I I j- I, I { ` I • .I IT i l~a.~r 4~ - I I j _I I_ II• I i.. _ I i - ~ _ i._. , , t ~ : r -r- 1 I I I C 1 I. I f I j r ! ~ I I { I ! I I I ~/~k II s~ fir , ~ I I i I I ` - dri I I ! I I- ! i I I ; - - I I I ~ ~ I I I I j : I , , I I I I ~ I - III ~ ' / - I - - - - L l } ' I I 1 1 ~ I i E t i 4 i I I I i ' I I ! I ~s ~ I l I I I ~ I I f i I j f I I ( I j I _ - - - - I - -Al fi I I I I I I I I 1 i 1 f- t I -I i I i I I I ' I I Ile. - l - - - i i I I j I I I i -i I - - --i r- r - I j I - I I I ' t ' I ! j f i I I i I i I i I , I i I I ~ I ' , I I I ~ ~ I I I i I I , I I , i a I I L ~ r I I 1 i~ ~ c ~ ~ I I I I ` y I I I I - - - j - r I II ~ ~ F I I I I I j I I I . r I I I _ I _ L ~ I I i i ~ a I I - r , ~ ~ I I t , f I r- - ~ ~ ~ i I i I I I ~ ~ I I I I I 1 ' f r ' I i I I ~ i fi r I I I 1 I I , I i i ! I I ~ f , _ I -41 , I ' I I ~ i I ' ~ + I I' I --i r _ _ } 4- L A Cro I e-e-C. r1 p 1 /l ~C17 ~~Sic'n-~ 4 Fresh Alt 1111811, And OlIke(vollon pips Appror:d Vent Cap Minimum 12' A°ove final Grad• s'~Qi7 20. 42' ADora Plpp _ 4' Cost Iron To Final OredS Vent Pips Mar ef. Net Or Synih lk Co,sting 'uln 2* Aggregate Over PIP$ DlalNpvllon PIP& o a 0 - Tea 6' Aggregate Beneath Pipe ° Perforated PIPS hotor o CO-011"11 761MIM.1ing At Bolcom Or System pptjp ep ~~cJ•.7 toll / SOIL FILL DISTRIBUTIOMi PIPE Y APPROVED S49THETIC COVCII ° "~-/1ATl=RII~t OIL 9. OF STRAW 2"o,F AGGREGATE OR MAStSN HAy -L4 t' a 7~,, ELEV. OF1~iQii Lt0F!2-21/2 AGGREGATE N)rc~v. F EET-_ DISTRIg'JTIUU PIPE TO BE AT LEAST ,21 IUCHES BELOW ORIGIUAL GRADE AUU AT LEASTZO IIJCHES BUT 1,10 MOrkC THAI) 42 INCHES BELOW FINAL GRADE MAXIM UM DaPrH OF F-XCAVAT100 FX011 ORIGWAL 6~AK WILL BE _ IIJCHES 7r N)MUM CK7PTli OF EXCAVATION FROM *L,~16If AL, 6RnoV- WILL BE - INCHES SIGIJED: L I C C U S C CI UM BE11:._L DATE: i DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING INDUSTRY, O LABOR AND PERCOLATION TESTS (115) P.O. BOX OX 7 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.090) & Chapter 145.045) C TOWNS IP/M I9Ir_1rzt1TY: UO.:BLK. .:SUBDIV ION NAME: LOCATION: 4 SECTION: Y/D 1(or ITSt P -SAW A) TY: OWNER'S/BUYER'S INIAMEE: MAIL NG ADDR7ES.. USE DATES OBSERVATIONS MADE NO. BEDRMS.: 1COMMERCI A DESCRIPTION: PROFILEDESCRIPTIONS: iFERCOLATION TESTS: Residence 1 1: YNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system ~G a r2s OTI❑~ . M®~. IN G©~ ND-PRESSURE: TIS TEM-I©ILLHOaLDING©NK: RECOMMENDE~~~E(optional) U S Ur,,1 1 If Percolation Tests are NOT require DESIGN RAC i If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF IL WITH THICKNESS, OLOR, URE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HI HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- ~ B- ' r - - B- ~r NA" n B- PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PER D 2 P R PER INCH P_ P_ s -1d P / 7 _60 4 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 surface elevation at all borings and the direction percent of land slope. SYSTEM ELEVATION JK' 3 [ E 4 ~._...._r_.. i - - - - 71. i i 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 Wisconsin Administrative Code, and that the data recorded and the location of the tests are c y knowledge and belief. NAME prin TESTS WERE COMPLETED ON: A S; CERT FICATION UMBER: PHONE NUMBER (optional): 014 1 C nxzal DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - IN' ...J TIONS FOR COMPLETING FORM 115 - SB®- - i To be a complete and accurate soil test, your report must include; 1 . Complete ' =scription; 2. The use =gust clez pis is a residence or coat it ; project; 1 MAX[( nber of I.= rns or I use planned; 4. Is this a r =place:.- _,tern; C[ 1, Lability ing boxe.. SUITABLE FOR A HOLDING TANK ONLY IF ALL v ,TEMS ARE RULED Ol. - _D ON SOIL CONDITIONS; d ( the abbreviations shown he -iting profile descriptions and compli plan; " 1IBLE diagram accurately r, f Your test [ocatlo l A I v f rise(] if desired; 8 in rk and vertical r, , "Clfevence point 3 C boxes as to da nar yes, addresses, floor -1< percola,_ion tee ` ex~ :np- t 10. ~r ar flood play does not appl", pf' N.A. in th^ al .~~~~=riate box; 11. Sign t' ;'our C116-ent 1 y~xtr certificate 'r; 12_ . distribute ALL SOIL T''; `GUST P STN THE 1-Y WITHIN 30 DAY PL T1C)N. VIATIONS : t_ ~ER1 y _ . L TESTERS Soi' Textures mbols st cor) gE. _ 3") B1 G y i W C' B VRP TOWEL I a sar;a.,~y rest 0 rig, r