HomeMy WebLinkAbout038-1125-20-050
) 00
Q c 0
a p 69
M
!r „N+ 0
0 C
I G
rte. I
Q
e
ell
N (D
N
zz +
O
~O
Q (VO
I
C
N '
Gz,~ C i
Q)
E
N U
N
0 o c
C Q)
7 Ca O
LL O O
o
v y
Q N
Cl)
ICI a)
co E
O
22 Z
O
Z ~ d m ~
w II a m
MF-z
o I
c C7 cfoi
o Z c
N Z? 2 c Z
H r
91 (D
C E "O
CO
a) a)
N O
N a
u O a
(y~
N a)
N
~'•~11 O C
N a)
• A~ CL U) 'C
co
o aa) Q w
Z co z o
N
O N 7~ N
N ~ N
O-' O O w C ~O W d i O O 2 OO
O; p p a E iD M
p~ Q p fn !n fn O O N
V7~ Z M > p F- F F- d (n
a
0
• ►ua E m Oa a Z C)
Z;
U
3 O N m 0)
y
N U o m (D
Z o
O O N O
W O = I
L CTJ y -Q-
N N d Q Q
}r\~ O C N Ul
►+i a 3 co m E
O CO H O N O O O
O~ C a C N CL O
tD O (6 O' 'D
c
N M C' o O O
3 N
0) (D
~ M M w0 L y m E U
• y~,~' O M fn fn O `n =5 to
O ~
ma
3 - L: a
CL a)
~ o 0o
0 E 0 0
A U a 0 cn 0
x
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
-t-7,1 ~ fi? C e1
OWNER Pere TOWNSHIP ✓ c~ Ert P
SECTIONT 3I N-RW.
ADDRESS ~1 - A► f ST. CROIX COUNTY, WISCONSIN
V---Jt
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
INDICATE NORTH ARROW
BENCHMARK: Elevation and description : _
Alternate benchmark )S G 9
SEPTIC TANK:Manufacturer:
✓t/'P Liquid Cap.
Rings used: -1 Manhole cover elev: 103.<'& Final grade elev: O
Tank inlet elev.:1®V,~2 7 Tank outlet elev.: 991
No. of feet from nearest road:Front Side , Rear Ft. >
From nearest prop. line:Front ✓ , Side , Rear Ft. i
No. of feet from: Well C 0 , Building: 4
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
f
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: V~ Trench: Seepage Pit:
Width: /I..), le Length Number of Lines: ,1--, Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front Side y, Rear Ft.,1*9
No. feet from well: / No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
/ ,INSPECTOR:
DATE: r1 PLUMBER ON JOB:
LICENSE NUMBER: M
6/90:cj
{i
1
i
f
i
f
f
4~l
t
j)7}f
1
(rj1
Vq,
s
a
U ( I
I-j
J TV
acual
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
Safety and Buildings Division NE! , NE%, 31 , 31 , INSPECTION REPORT Sanitary St. CPermitroix
GENERAL INFORMATION 18W, Lot~3, Raleigh IPERMIT) 149213
Permit Holder's Name: ❑ City ❑ Village {Y] Town of: State Plan ID No.:
Brenda Strohbeean & Bryan Shil s Star Prairie
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
038-1125-200-50
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION B HI FS ELEV.
Septic l~Q Q r(C, O Benchmark Av /®O tv r
Dosing 1. M p'p" /07
Aera ' n Bldg. Sewer
olding St/ Ht inlet 7 27
TANK SETBACK INFORMATION St/ Ht Outlet t p 1
'g 310 916
Vent
irIto ntake ROAD Dt Inlet
TANKTO P/L WELL BLDG. A
Air
Septic NA Dt Bottom
Dosing NA Header
r 'r
eration NA Dist. Pipe
Holding Bot. System ' y 40~
19 PUMP/ SIPHON INFORMATION Final Grade
3~ 0 3
Manufacturer Demand S,T. Le r
el Number GPM
TDH Lift Friction TDH t
oss ea
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O oo- r CHAMBER Model Number:
as System: ( 41 s- OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
,rb SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 7Bed/ h Over xx Depth Of T xx Seeded / Sodded xx Mulched
Bed /Trench Center Tren ch Edges Topsoil E] Yes 11 No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
Plan revision required? ❑ Yes to
Use other side for additional information. j Q Y-
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
i
SANITARY PERMIT NUMBER:
i
SANITARY PERMIT APPLICATION
Y
Lot!. R In accord with ILHR 83.05, Wis. Adm. Code COUNT
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ~O~ l
8% x 11 inches in size. 1:1 cheHkI ev ision 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 PROPERTY LOCATION
}ro bsQ a /f F'4 NF Y4, S 3 / T 31, N, R E (or
PROPERTY OWNER'S MAILING ADDR SS LOT # BLOCK #
/t4
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
~1JC/clt k Gul S D 7 t/ i/.S ?~f7-3 C. o f 2 c/e
II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE : NEAREST ROAD
=N RF:
X NUMBER( b)
❑ Public [A 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL
III. BUILDING USE: (If building type is public, check all that apply) 3 1 Z 0-a-
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 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. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 ❑ SpecifyType 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) .11 ELEVATIQN
22- 0 -7 Z O ea L 5 G 3 g• 0 Feet jP 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 Holding Tank /4000 +i 6'r Dd F] F1 F] _X+_~ Ej 0 El El El
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: (N Stamps) MP/MPRSW No.: Business Phone Number:
o~ 5~'/otib r /t) ,Al )a 513,2 2y7 32-3
Plumber% Address (Street, Cc~ y~io a S 017
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued issuing Agent Signature (No Stamps)
Approved E] 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. Yo6f sanitary, 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.
Vlll. 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% 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 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)
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 $r~N~►.~ ;+rokjpemf, &ruain Sh% (t5
Location of property_N_F 1/4 ~kF1/4, Section _J) , T_jLN-RJ~
Township Sia -
Mailing address -73,V L.L. //tti st A/y /E0.G 4- rlioa r Syai7
Address of site ,Pa/~%yh Ico.eA Lof'~-
subdivision name Lot no.
Other homes on property? yes X No
Previous owner of property
Total size of parcel z_oo ~~sr5
Date parcel was created 4-17-9V
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? Yes a' No
Volume 4_and 'Page Number 2-qy7 as recorded with the Register
of Deeds:
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. 7_1 O , 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. -1- 7 1C, 6 - .
-4 L
Sign ure o applicant Co-applicant
Date of Si nature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA
QUIT CLAIM DEED
. 46"4089 VOL 917rAGE 08
- REGISTER'S OFFICE
'00 gArm 4 •e 1Cz ST. CROIX CO., WI
Recd for Record
S 111' 11 01991
quit-claims to JlP at 1
I.10 A:4
~I
a
Register of Deeds" '
the following described real estate in County,
State of Wisconsin:
^ / RETURN TO
/V
Tax Parcel No:
This-) t d homestead property.
(is) (Is not)
Dated this -S day of 19.
(SEAL) (SEAL)
Of
pry I !-d ~ ~2
E (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
St.
County.
(AA9t'4
authenticated this day of 19 P rsonal came before me this 37 day of
19 the above named
i7
k .60W
TITLE: MEMBERSTATE BAR OF WISCONSIN
(If not, to me known to be the persons who executed the
authorized by § 708.08, Wis. Stats.) foregoing Instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTEE BY
Notary ublic County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is per anent. if not, state expiration
are not necessary.)
date:
ouaia . S ohibera
Names of persons signing in any capacity should be typed or printed below their signatures. Notary Public SB3 NTF 0023
Hudson, St. Croix County, Wis.
QUIT CLAIM DEED STATE BAR OF WISCONSIN My CO rr1~ M'-.,r^e III~( _I r) 1rrV)
L_ _ r ^ n , , 11 ' n " 1 , T-4V FArrr< 3'40,, 1008 ~GrPen Rav WI 54307-0209
CERTIFIED SURVEY /MAP NO.
VOLUME _ PA6E
LP. TED : I1`1. N_Cy!TEPi'.,:QU RTVA, ; aFi `T~R'I#F+a~S~€} ?tk3~tT1~'AIVD.: ; IN THE
AJIL114 ",JR S£ CT_Z1Q T?:~ 1 , TOWN-
$;~i.F13:.Tl~t{.I; R~~TFr~~$I~kFr!'~. TOWN OF STAR PRAIRIE, ST. CROIX COUN-
PREPARED FOR: Douglas and Margaret Strohbeen TY, WISCONSIN.
R.R. 4,
New Richmond, Wi. 54017 (715)'247-3233
PREPARED BY: Lee Villeneuve, R.L.S.
R.R. 6, Box 150,
Menomonie, Wi. 54751 I"=100'
LEGEND SCALE //V FEET
ST. CROIX COUNTY ALUMINUM MONUMENT FOUND.
3/4 INCH. x 24 I1TCH IRON RE-ROD WEIGHING 100, 0 I '
1.502 POUNDS PER LINEAL FOOT.SET.
MAP $MAR-:INGS _-ARE; ; REFERENC-
TO THE NORTH LINE OF
11~ ♦i THE NORTHEAST QUARTER
NC>GOIVS.~~~j~♦, OF SECTION 31, T-31 -
N, R-18-W. ASSUMED TO
LEE F. BEAR NORTH-89°49' 25"-
V L UVE WEST.
Y
S (o ~
,,♦♦♦OU ~ S CORNER OF
too 1 ,
T-31-N, R-1 8-W
N-89°49' 25"-W N-89°49' 25'_ W
NORTH ~ CORNER OF 1555.42` 1119.07'
SECTION 31, T-31-N, NORTH LINE-NE4 31-31-18
R-18-W
8
I VV
3 3 v~
3' f 33/ f = =M.~i
F- M V6 ~O
U N P L A T T E D L A N D 0 ti ofV A
2I - - - - - - - - Inv
CIO
E
;u 435, 6p' sp0
° R M 8
cui a I
Q, a
• LOT - ,
ar 2
2r ~
°r 18 -87,120 SQUARE FEET = 2,00 ACRES EX- CLUDING ROAD RIGHT OF WAY.
338 193,721 SQUARE 'FEET 2_T5 ACRES IN- 0IS
~
c ` ,33 'CLUDING- ROAD RIGHT OF WAY.. No
N`'so 3g 61V j , UNPLATT12
/ l s5,311 = LAND
46B 6t) ,
U N P .L A T T E D L A N D
'This ,instrument was drafte6. by Page 1 o f ? sheets
Bruce Villeneuve
o~' SINN w
•
•31NOWON31M
'3 331 ,
ti
~•i N0'JS~
sgaaq~. Z.30 ~ ?b.~d ~~~~I~ttNN~N~s'►
'ON 'W 'S 'O 1661 'LL aunt 'D,860# 'S'Z',U 'aAAaNa'PIIA 3a'I
•awps agg buzddpw pup buTpzn-rp 'bUTAan.zns uT a u zp10
uotstntpgnS AqunoD xtoaO •qS aqq pup sagngpqs uzsuoOSTM aqq ,jo
t£'9£Z aagdpgO jo suotsznoad aqq g4Tm pazTdwoo anpq I 'paAan.ans
pupT aqq 30 aTpOs Oq uoTgequasaadaa goaaaoa p sT dew eons
gpgq Pup 'PupT PTps 30 s.zauMO 'LLOtg 'TM 'Puowgotg MaN 't
•g•g 'uaaggoagS gaapbapW I SeTbnoa jo uozgoaaip aqq qp dew
pup uozsintp 'Aanans eons appw anpq I gpgq AjTgaao I
•paooaa jo squawaspa pup sppoa oq goaCgns Aanans PTeS
•buzuuTbaq
jo quzod aqq"'a.Tgaa~ 09'S£i~ 'gsea-„0£,SSoSL-ggnoS aouauq
:po,z uoaz up oq qaa; 00'00Z 'gspa-„0£,T7O,~L-g4aON 90u9gq
:poa
uoai up Oq gaaJ 09'S£t 'gs9M-„0£,SS.SL-ggaON aouaug :poa
uoaz up Oq qaa; 00'OOZ '4saM-„0£,f,0.VL-ggnoS aouauq
!pegTaosap uiaaaq Taoapd
aqq jo buzuuibaq jorquzod aqq a03 poa uoai up Oq gaaj00'tt£L
'gsaM-„tL,ZZ.ZS-ggnoS JO butapaq pawnssp up uo aouauq
:gs9M-8L-9bupg 'ggaON-L£
dtgsuMOy 'Lt uOTgoaS jo aauao0 gspaggaoN agg gp bui0u9wwo0
:sMOTTO3
sp p9gza0sap utsu03STY, 'Aquno~= s o~q p' p b<; Mo
aqq 30 104atho lIsgAgq&ORU:190'jdoll@@SOL3
-gapno gspaggaQR agg ;o 4apd paddpw pup papznip 'paAanans anpg I gpgg
A3zgaaO Agaaag 'HOAaAHaS QNvq aauaisiDaa 'aAnaNHggIA aaz I
SS ( uuna ;o AqunoO
(uisuooSTM JO OgegS
ag1123T -T90 `saoAananS
SEPTIC TANK MAINTENANCE AGREEIIENT
St. Croix County N
014NER/BUYER ~ ' ~-trohba.~ ` B6'uexr~ 5 W ItA o
ROUTE/BOX NUMBE Fire Number--
CITY/STATE ai ZIP -I-- -
PROPERTY LOCATION: k•,_Lk, Section _3 T_.3j_N, R~
Town of S't= i St. Croix County,
Subdivision G.S.A. Lot number -3- .
Improper use and maintenance of your septic system could result ein
con-
its premature failure to handle was
sists of pumping out the septic tank every three years or sooner,
if needed, by a licens'ed' 's'e t'ic tank pumper. What you put into
the system can a ect E he .unct on o, the-septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix Count residents'-may be eligible to recieve a grant for
a maximum of 604 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 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)•afterinspectind pumping
ludge and scum.
essary), the septic•.tank is less than / full
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as.set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Offi evwi~thin 30 days
of the three year expiration.date.
SIGNED 1 h
DATE q
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016.
386-4680
Sign, date and return to the above address.
S T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
°INDUNpUSTRY DIVISION
LABOR AN P.O. BOX 769
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(1-163.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/M4~I41CIPALITY: O. O.: SUBDIVISION NAME:
'/0','/ /T NIR V(or
F 1
COUNTY: O bee M ING ADDRESS:
USE 62•~ DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMER I L DESCRIPTION: PROF D S ONS: PERCOLATI
TESTS:
®Residence ~ New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: II.N-GROUND-PRESSURE:ISYSTEM-IN-FILLIHOLDING TANK: RECOMMENDED SYSTEM:(optional) ,
I
(1 S ❑U D S 0U ®S ❑U ❑ S ®U S ®U
5--rr . s
If Percolation Tests are NOT requir DESIG RATE: I If any portion of the tested area is in the
under s.1463.09(5)(b), indicate: Il Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED ES I H TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 116 A /1
s
B- 3
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D PER INCH
P. / A&AtZ S7
P-w2 216ZA6~
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
I
~ ~ ~ t i I I t I I t.•_._ l
i
I
l
A 1 I J
1
t
I, the undersigned, hereby certify hat the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME r' t : I TESTS WERE COMPLETED ON:
ADD CERTIFICATIO NUMBER: PHONE NUMBER (optional):
C SI N U E•
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
` a
w
ism=oi
-d N
r
Pia A P -1~
N -
A , r ~
_ _ e N
~ v u n
P ♦ r o A
411 o
w
O - P
9
• ❑ I~ w
ad
o PN P
~ = I
~1 ► P U ro P
6
F -V
d' Ir v s
~ P
0
op
n r
J o _
z
m
n
E.esf/of 200,
i
l .pa
I
z j ~ 1
x I I
I
I
~ f ~ z Z i I -p„ I
1 I
O h ! l
r~ lil < I I I
'f rn a I I ~
p ~s. z r
I I -o I
I
f i rn I 0) i (A -00
f
I I l
it < 1 ( I
f I f
A 1 f
~ I ~ 1 1
rn ~ I ~ cn i
s i I ~o f
n C: !
D II i i '0 ~ i
fI I W I
m jl I I
r
i
W
cq
i
e I I ~
Z ~'m
O (9-` F
n Q. N mi
`ri ~Lrr
Y ~ to K3
~ u
? Eo P R
in
J P
s
Ov
np
cA 3 .
~Aj~ S
N
3
NT OF REPORT ON SOIL BORINGS A D SAFETY & BUILDINGS
DIVISION
AN° PERCOLATION TESTS (115) P.O. BOX 7969
AN RELATIONS MADISON, WI 53707
ICATION: (H63.0911) & Chapter 145.045)
a j'~ SECTION: N/R Vlor TOW~IISHIP/M6kW CIPA~LITY: OT NO BLK. O.: SUBDIVISION NAME:
1Tzj *
COUNTY: /1~ O M wj 6,,p M ING ADDRESS:
I USE 6* DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMER Cl L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
®Residence New ❑ Replace
0 1'/
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLD ING TANK: RECOMMENDED SYSTEM-(optionalI
❑u oS ❑u ®S ❑u ❑S ®u ❑S ®u ,),10.Z
If Percolation Tests are NOT requir DESIG RATE: 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 SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
B- 91-
,2 C
B- R
B- 161 ' AO"' A49A~F J"6f 'got
/ -
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L VEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- 1
P- ?
P- S.
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 ~3f ga? '7
f s.
4e
E
--J tN
I
i
f
f 3 i04P
4f -14 ~01
I, the undersigned, hereby certify hat the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME r' t): 1 TESTS WERE COMPLETED ON:
e5
ADD CERTIFICATIO NUMBER: PHONE NUMBER (optional):
/
C SI N U
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
1
INSTRUCTIONS FOR COMPLETING FORM 11 - S6D - 6396
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 numbei of bedrooms or commercial use planned;
4. Is this a new r- - -rent system;
5. Complete the s it .6lity rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLFASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; ~
7 E A LEGIF' '7 diagram accurately locating your test locations. Drawing to scale is preferred. A
..e sheet he creed if desired;
B. M sure your t rk and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all app riate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tir f appropriate;
10. 'd information (such as flood pla "ovation) does not apply, place N.A. in the appropriate box;
11. : form and place your cur r ress and your certification number;
12= Make legible copies and distribute : re<luired. 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 - Sandstone
gr - Gravel (under 3") LS - Limestone
*s - Sand HGW - High Groundwater
cs Coarse Sand Perc - Percolation Rate
med s - Medium Sand W - Well
fs Fine Sand Bldg- Building
Is - Loarny San(] > t rter Than
xsl - Sandy Loam < I T'' in
*1 Loam Bn
*sil Silt Loam BI I ck
si - Silt Gy - Gray
*cl - Clay Loam Y Yellow
sel - Sandy Clay Loam R Red
sicl - Silty Clay Loam mot - Mottles
sc Sandy Clay w! - with
sic - Silty Clay fff f , fine, faint
*c Clay cc - r, coarse
pt Peat rnr- - y, medium
rn Muck d - ! stinr
p - prominent
HWL - High water level,
Six general soil textures surfao w rter
for liquid waste disposal BM - Bench M
VRP - Vertit tce Point
TOT'
T' ' I a I unty or the Dep. n. iy r- guest
s plr of Y': "te
sy° a th o al
a permit. The s y nit r >d prior to t' of
L