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HomeMy WebLinkAbout038-1042-70-000 00 ~ 03 I o > a a w ~ I °o N h I N 9 Z c LL C O Q M r Z y to O z r d y o z a m o I 0 2_ c z N H S ~ o ~ ch I N O C m O h N I O o N z co z z N _ o d N ~a E ~ I CL 2 C (D }y C v c H 41 m m - N 0) 0 C O D d U c O 0 co 3 zo •N ~aaa R y CL z o N (A J V p rn rn } O co N U') co O O E US ml N C CL 0 4) _ O 'p d Q fn (6 O 0 7 0 p ~ A W = O m 0 1 N O C E v O CO N fC O C C a p l (on C N c N E C f6 N O r 00 p a N LO y Z L .0 e' i N H N • *4 ob Cl) o d v o 0 o E ►~i o u~ o z Cl) s~ ~ II V a , 0 a .G C c rrww ~ r ti 1_ FORM - STC - 104 i AS BUILT SANITARY SYSTEM REPORT OWNER 45~'Arjl G TOWNSHIP 5~u SECTION_y/,2~2 T ,LN-R_W ADDRESS ZO ST. CROIX COUNTY, WISCONSIN jgg &elcd 12, C 4 c yr, 0.h / S-f-0 / 7 SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r (j-ao5~ ~~/e~ ~ I I 3 f y~r sr - / wL INDICATE NORTH ARROW BENCHMARK:Elevation and description: d Alternate benchmark &1 4- C L~5c r v v SEPTIC TANK:Manufacturer: lCf Liquid cap. / &32::~e Rings used:'- Manhole cover elev:,lg -"Final grade elev: y Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side, Rear Ft.? g Ft.~ From nearest prop. line:Front , Side , Rear No. of feet from: Well D G Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE J 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: X Trench: Seepage Pit: Width: Length Number of Lines: Area Built y Exist. Grade Elev. ZZ /15~ Proposed Final Grade Elev. Fill depth to top of pipe: PTO. feet from nearest prop. line:Front , Side , Rear Ft. l3 No. feet from well: No. feet from building t~.3 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: I INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & EJUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING cMADISON, Wt 53707 A-q160 / J%,NE4, SW4, Sec - 10, T31-R18 10cONVENTIONAL DALTERNATIVE State Plan I.D. Number: Town of Star Prairie El Holding Tank ❑ In-Ground Pressure ❑ Mound Ilfassigned) Goose Lake Rd. NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE. Gar Jessen 1040 220th Ave., New Richmond, Wi &02141 - BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. / a REF. PT. ELE EF. PT. ELE q~ Name of Plumber. MP/MPRSW No. Cnunty. Sanitary Permit Number: Byron Bird Jr. 3318 St. Croix 149056 i SEPTIC TANK/HOLDING TANK. 3 5.: rg,kk ems, z.97 MANUFACTURER. LIQUID CA ACITV. TANK INLET ELEV.. TANK OUTL V_ WARNING LABEL LOCKING COVER PROVIDED PROVIDED (/~Cw_/l rllljr O/. ~U/i 2.~ lld'YES QNO OYES 1RO BEDDING: VeWT DIA.. WeNTMATI HIGHWATE" NUMBER OF ROAD: PROPERTY WEBUILDING JVH C_ C. ALARM FEET FROM INE AIR OYES LaNO YES NEAREST .I I DOSING CHAMBER: ~1ANUFACTUR ER BEDDING: LtOUID CAP ACI TV PUMP MOUE I. PUMP.SIPHON MANUI ACTUHEN WARNING LABEL Ho ING COVER PROV ICEDVIDED: OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NU. F PHOPEHTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FRO LINE AIR INLET. PUMP ON AND OFF) DYES ONO NEAREST-O- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing l NC:T If DIAMF TIE It HIAL AMU MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to contin / MAIN ; CONVENTIONAL SYSTEM C" S c, s BED/TRENCH WIDTH GTH NO OF UISTH PIPE SPACINI, COVER INSIUL UTA -PETS LIQUID / / THE NCHF$ / MIT PI` DIMENSIONS GRAY L DE H FILL DEPTH UISTH PIPE UISTH PIPE DISTR. PIPE MATE L NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BE LOW PIPES / BOVE COER EI FV INII I ELEV ENU LINE / II A ( C 1 10'~- Y FEET FROM ) AIR INLET ~7 -27 cO/ro,S/ X726 NEAREST---► MOUND SYSTEM:;? 77 Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGR41M OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- O YES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PFHAtANFNIMAHKFHS OHSEHVATIONWELLS _ OYES ONO [DYES ONO DEPTH OVER TRENCH BEE) EPTH OVF N THENCH IIEO :IPTHM T()I'SOIL isom)FI) ISFE OF I) MULCHED CENTF.H EDGES OYES. ONO DYES ONO ❑Y ONO PRESSU ED DISTRIBUTION SYSTEM: I'll WIDTH LENGTH NO. OF LATEHAL SPACING GRAVEL TH HE LOW PIPE FILL DEPTH ABOVE VEH B /TRENCH TRENCHES. IMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE IM ANIFOLD MATE NIAL NO UISTH UI DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. DIA ELEV. PIPES DIA: ELEVATION AND DISTRIBUTION INFORMATION < "OLE SIZE HOLE SPACING DME.LEU COHHECT LY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: OYES ONO OYES ONO NEAREST / Sketch System on Re in county file for audit. Reverse Side. SIGNATU TITLE: DILHR SBD 6710 (R. 01/82) rm7 , ( DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code C:° b STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8%x 11 inches in size. nec if revision to eviousapplication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE OWNER PROPERTY LOCATION j--GSs~ %a S T , N, R E (Or PROPERTY OOWN S MAILLtIG ADDRESS L T # BLOCK # C , ST E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER /lea ~ Ol 1:1 ITY II. TYPE OF BUILDING: (Check one) L1 State Owned C VILLAGE: ~ f of ,G NEAREST ROAD ❑ Public VL1 or 2 Fam. Dwelling-## of bedrooms A ICEI TAX U FRO / dr L ,P III. BUILDING USE: (If building type is public, check all that apply) L DZ7 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 40 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. V yVew 2.E] Replacement 3.E] Replacement of 4.E] Reconnection of 5.0 Repair of an r2A 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~ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Z4 ~0 5 ?4-0 1 1 • 40. Feet fl 4A ;2 Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New xistin 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 the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Si e: (No Stamps) MP/MPRSW No.: Business Phone Number: 611 r l Plumber' dress (Street, City, State, Tip Code): IX. COUNT /DEPA TMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (No Stamps) S ~~~111111 Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety S Buildings Division, Owner, Plumber INSTRUCTIONS , 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of ronewal 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. i 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: I. Property owner's name and rrTailing 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. Ill. 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 13% 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 tan'Ks; building sewers; wells; water mains/water 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) i APPLICATION FOR SANITARY PERMIT 9TC-100 This oppllcstlon form In to bo conplntod In full and signed by the owntr(s) of the property being developed, luny lnadoquaclea will only result In delays of the pit rnlt Ialuanca. -Should t h I a development be Intended for retala by owner/contractot,(apec house), than a second form should be retained and completed vhan Ilia property Is mold and submitted to thla office with t h a ■pproprlatt deed rteotdlnq. OvnIr of property SSEW Location of property 1/4 A Z- 1/4r BtetIon - Ski~ T J N-R/9 Y Tovnshlp 14&11 lnq address _ Nil QA46C , Sy~;i7 Address of alts CG~sL,~--I~ lubdlvlslon nawt ' Lot nuebar i1 Pttvlous ovner of property Art'-tC~/ Y p-~eeso in Total size of parcel <-10 ~9C✓ r'S e Date parcel vas created Ara all cornsrs and lot 11nes Identifiable? U Yes No Is this property being developed for remale (spec house)? Yes No Yolur.r 3/ and page Humber 12S s■ recorded with the Reglstec of Deeds. IHCLUD9 YITN THIS APPLICATION THE FOLLOwIHCt A VXAR"Tr DQID which Includes a DOCUHRHT HUNnIR, VOLLNK KXD PAO[ I4VNIIR, and the SILL of TIIL R9019THR OF DERDa. In addition, a eettleled ■utvey, It available, would be helpful so as to avoid delays of the tevlawing process. If the deed description references to a Cettlelsd Survey Hap, the Certified Survey Hap shall also be required. ----------------------7--------------------- PROPERTY OXnI R CERTIFICATION I(vv) certify that all statements on this form are true to the beat of my (our) knovledgeI that t (we) am (arm) tha owner(s) of the property described In this Intotmatl I on form, by virtue of a warranty deed re orded In the ottice of the County Avg Iatat of Deeds as Docurnant I(o. ~jell</S/~ and that t have presently own the proposed alto for tho news a dla oral a atejnl (or I e) ave obtained an easement, to run with the above daaccIbad propttty,(vIor ht.he consttuctlon of sold nymtem, and the same line been duly recorded In the office of the County Reglstor of Deeds, as Document No. y Si/ ~fw n A Signature of Co-ow-ntr (I[ A llc&b PD le) 5 ~y-ci Date of slynatuta Date of Signature DOCUMENT NO. I THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-19821 444511 REGISTER'S OFFICE Bradley N. Peterson ST. CROIX CO., WI Rec'd for Record 1 i~3J at JAN 3 1 P M conveys and warrants to _.Garet.-.A.--_.7SSsen........................................ a ~~ay +l~X Register of Deeds . RETURN TO _ - County, the following described real estate in •----St-. - Croix- • State of Wisconsin: I~ Tax Parcel No_ The South Half of the Northeast Quarter of Southwest Quarter (S4 of NE4 of SW4), EXCEPT the North One (1) foot thereof, and the Southeast Quarter of the Southwest Quarter (SE4 of SW4), EXCEPT the South 680 feet thereof. ALL in Section Ten (10), Township Thirty-one (31) North, Range Eighteen (18) West. This deed is executed solely for the purpose of fulfilling that certain land contract between the parties hereof dated November 9, 1987, recorded November 10, 1987, at 8:30 a.m., in Volume 1179611, page 264, as Document No. 431986. TRANS li FEE This is-not.........- homestead property. II (is) (is not) j~ Exception to warranties: Ii Dated this -----9th--•-•-•--•----------•- day of JcdnLlc'lry------------------------------------------ 1989-- I~ I ---------------------------------------------(SEAL) Bradle N. Peterson i (SEAL) (SEAL) * * I 'i AUTHENTICATION ACKNOWLEDGMENT , Signature (s) STATE OF WISCONSIN . ss. St Croix - t County. authenticated this day of........................... 19...... Personally came before me this 9th----- day of January_____________________ 1889_-__ the above named Bradley N•.---Peterson-------------------------•--•-•-- j TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me own to be ;the person who executed the fore i g instrl}In b` "d 'b1h%owledge the same. THIS INSTRUMENT WAS DRAFTED BY ~l © Reinstra, Van Dyk & Needham, S.C. Att-arneys-__at---Law------------------------------------------ * RLJ: h. s 0 - l -w c)imond~__ s Wiconsin 54017-0127 Notary Public .i_ G 9 7 ----...-.-.County, Wis. g;n}~>ael~tQIfanot, state expiration My Commission isPpU l7 l.• (Signatures may be authenticated or acknowledged. Both _ are not necessary.) date: ._1 2/~2-9Q - - 19.._.__...) ~J- - *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN - Wisconsin Logal $Innk Co. Inc. FORM No. 2- IJ82 Vilwi-kec. %Vis. SEPTIC TANK MAINTENANCE AGREEMENT w St. Croix County n 'Ot,TNER/nUYER re o ROUTE BOX NUMBER Fire Number /0 f7~0 d CITY/,STATE L) 1 ZIP -~y7 /7 PROPERTY LOCATION C` k-I eE , SectionSw'q,• T_ I R_ , Town of St. Croix County, Subdivision Lot number- Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licens'ed' 's'e t'ic tank um er. What you put into the system can a ect t e' unct on o. t e•aeptic tank as a treat- ment'stage in the waste disposal system. St. Croix County residents'-may be eligible to recieve a grant for a maximum of 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 's sY tem_s 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- 30fdayssludge apthan 1/3 proximatelyfull priordto essary), the sfoormcwillkbe ssentless Certification 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 Natural tResources. oix Cer,ification Zoningo0 ficetwibe c thinm30edays and returned Co of the three year expiration-date. SIGNED DATE y - 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 INDUSIr RY,: DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WOI 53707 'i HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SEC ION: N/Rl (or NSHIP/ UNIAALITY:( O'T`NO-.:BLK_ NO.: SUBDIVISION NAME: COU TY: MAILING ADDRESS: / Goo , ~ ~ o z ofd ~ off, ' o CJ ~.~f~oi USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILET Residence New ❑ Replace _ p d RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEMM-IN-FILLHOLDIING TAN': RECOMMENDED SYSTEM: (optional) S EA c EA J EJU E1JZU E1 S ZU If Percolation Tests are NOT required D ESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: G~l Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) c- 13- O 02 B-3 B- B- c~ PERCOLATION TESTS } TEST DEPTH . WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES f NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD 2 P R PER INCH P_ O / P_ 3 ' 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 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. lao /o~• / G~ ~~<4 I d /tee',., -7 V V s o ..L /eel 8 ~Q 1 ( Al 0-9 J c~4 YN VAN* t 10, } iz-A 711 14 f - t Q 005 ! 4''' rt s I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedure ~d eth'c specifie in th 11tlis) nsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and be NAME (print): TESTS WERE COMPLETE ADDRESS: CERTIF CATION NUMBER: PHONE NUMBER (optional): GCJ o o ? 215_26V 76e CST SI N T E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R, 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability 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 scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur 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. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay Ill - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. FLU I PLAN PROJECT ~ahs~ ~~55 ADDRESS If-1%4 1/4/se /Tj/ N/R/46 W TOWN a~ COUNTY Ix Lc1i MPRS. Byron Bird Jr. 3318 DATE BEDROOM CLASS PERC~5-, CONVENTIONAL IN-GRO D PRESSURE CONVENTIONAL LIFT MOUND_ HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE Ilk. Benchmark V.R.P. Assumb Elevation 100' , Location of Benchmark , u ti e-- ® * H . R . P a r n eH/ (acs a ~u - M Borehole Q Well Scale Feet O Perc Hole System Elevation / Uent 12" Gr de TYPAR COVERING 2" 12" 3' 4 6' O 3' 3' O 3' 3 ` © 3 ` 1 " Sewer Rock 6 12' 18, 02 ~0\ Q ah 'q9 ~r