HomeMy WebLinkAbout008-1018-10-100
WPARTM6NT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & wUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, 153707 State Plan I.D. Number:
NW 4 , SE~ , Sec . 6 , T28-R16 J~i CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Eau Galle of
1~ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
nderMeer Rt.2 60th Ave. Baldwin, WI 54002
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: d
nPle E Hudson 6629 St. Croix 135547
SEPTIC TANK ~sU.*kvJo+'1l~n~a~efo`-{= ,liG~ :.U E lu-
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK T ELEV.: WARNING LABEL LOCKING COVE
PROVIDED: PROVIDED:
V.E / s (0tc. ~ C fi ►1 C ~o ~ 9~. Lr7 J. ❑ NO -1 YES O
BEDDING: VWT DIA.: - ? MATL.: HIGH WATER [NUBER MOF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
LINE: / ~ ( AIR INL T
,U, ~ of ALARM: ~ FEET FROM
❑ YES 0&0 c~S ❑ YES N NO NEAREST -11111' 5v z
DOSING CHAMBER:
MANUFACTU ER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
Y _ ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FR LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST ~
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: ikTF~jIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
W : LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH „r TRENCHES: IAL: DEPTH:
DIMENSIONS ! 94
- I V11
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DIST PIPE MATERIAL: NO. t TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW P PES: ABOVE COVER: ELLEEVV y ELEV END: f ' f PIP FEET FROM LINE: AIR INLET:
L !I i ra S:
NEAREST %.3
MOUND SYSTEM: 0 v~c.ti ' JE.Yrr,
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 MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING
COMMENTS: r FEET FROM LINE:
5 Ic~all~ ❑ YES ❑NO ❑ YES ❑ NO NEAREST
2125 SS-~- Avc .
Re in in county file for audit.
Sketch System on
Reverse Side. kSIGNATE: ~ TITLE:
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNT /
E:710ULHRO
x
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ id2 vision to pr ou' Cf
8% x 11 inches in size. s 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
✓ elf AA4S c/5 T N,R (or) W
PROPERTY OWNER'S MAILING A DRESS LOT # BLOCK #
iFf, Z 6Ale
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM ER
I
II. TYPE OF UILDING: (Check one) ❑ State Owned El VILLLLAGE : y ou O al NEAREST D
v J2 =N ❑ Public B1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX M R() ZZ B
Ill. BUILDING USE: (If building type is public, check all that apply) 2 - 2 8- 7 Z3 S
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
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 XNew 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
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
13 9', /7 Feet ~ 9ZZ:5Feet
VII. TANK CAPACITY
INFORMATION in allons Total # of Manufacturer's Prefab. Site Fiber- Exper.
New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks 5- structed
Septic Tank or Hold! n Tank O /OD F-1 F1 I El
Lift Pump Tank/Si hon Chamber El El I El I El I El
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:
--Da lc , AiW-- o n aZ - 4 ~ Z G041 J37e
Plumber's Address (Street, City, State, Zip Code):
IX. C LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing A nt Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee) Adverse D rmin tion
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
K '
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 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
sub"tted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a ficensed
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 film 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 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-8398 (R.11/88)
^ 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 1?2e /V~ r? L~y e Z=I-a 7
Location of property /l11V 1/4 Sh' 1/4, Section , T N-R /4~ W
Township Z-~ t4 62QIle-
Mailing address
Address of site
Subdivision name
Lot number 1
Previous owner of property ~6~vCl~Olerl .rlp
Total size of parcel X06
Date parcel was created _ 0
Z21
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)?Yes No
Volume 9Z Z and Page Number 13 / 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, 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 references to a Certified Survey Map, the Certified Survey
Map shall also be required.
---------------------------------------------------------7---------------------
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 warrant deed recorded in the Office of
the County Register of Deeds as Document No. Z 00 • and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been my recorded in the Office
of the County Regi ter of Deeds, as Document No.
Signature of Owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
L e~~K 82,' FA 139
000UMENT NO WARRANTY DEED THIS SPACE RCSERVED FOR RECORDING DATA
' STATE BAR OF WISCONSIN FORM 2-1982
441203 REGISTER'S OFFICE
ST. CROIX CO., WI
Recd for Record
M.ari_lyn.Bensts.on and Howard Bengtson,
her..spouse.......
S E P 07 1%8
at 8:30~JA. QM
convey. and t%arrants to Melvin H,•. Van.de.)rMeer
Rpbgr ~f DMda
RtTUP. TO
the following described real estate in St. Croix _._Co,lety,
State of Wisconsin:
Tax Parcel No:.....................
Part of Northwest Quarter of Southeast Quarter (NW4 of SE;)
of Section Six (6), Township Twenty-eight 'forth (T28N),
Range Sixteen West (R16W), described as follows: Lots
One (1) and Two (2) of Certified Survey Map filed August
18, 1988 in Volume 11711, Page 2012, as Document No. 990600,
Office of the Register of Deeds for St. Croix County,
Wisconsin.
l~:oo
:+_7 F
This 1S . homestead property.
(is) NK") I
Exception to warranties: Easements and restrictions of record.
s r•
Dated this day of 1988
SEAL.
Marilyn Bengtson
(SF.AI.I::I, (i f~ .r- " - tal$ALT
Howard G. Bengtson
01? 0
AUTHENTICATION AC KNOW LEDGMEX#e/
Signature (a) STATE OF WISCONSIN
...ST. CROIX
County.
authenticated this day of......... 19...... Personally came before me this day of
19. 88. the above named
Mari~Iyn Bengtson and Howard G.
. Bengtson
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not...
authorized by ; 706.06, Wis. Stats.)
to me known to be tht hoi-on S who executed the
fl revoine instroment rind arknowlc,l;re tiu• Slum..
T•,.S INSTRUMENT WAS DRAFTED BY
Thomas A. McCormack
Baldw WI ,400_
Nota-,v ruhl:{ 1 .'1111 c, WIS.
(Signatures may be authenticated or alkmrtclcd~,,l- B,nh My Cowl-its=iorl n r.l::1~;: . li nllt, >1;In• c:1~.-:,thHl
are not necessary.) (late: C < 19 ! I
•Names of perionn signing in any cat,acit) -r I,•- ,...,i ,,;nt•d h. ;ir :r:.:.
'WAR"?= DL=D STA'M BAR OF WlSCf`.NfiIV N.•• " I •r:.~ L.,, r
FORM No a- Lag U-,.
CERTIFIED SURVEY MAP
Located in the NW; of the SEa of Section 6, T28N, R16W, Town of
Eau Galle, St. Croix County, Wisconsin; being Lot 3 of Certified
Survey Map in Volume 4, Page 1123.
I lot 1 of-Certified
Nnplatted Lands Survey Nap in Vol. 4,
Wk Corner of Center of I Su "o 4,
j
Section 6 Section 6 Pg. 1123
North line of the SEk of Section 6
S o -S88 00'38"E 793.14=
393.14' 200.00' 200.00 ~ 55TH AVENUL
1368.111
393.14'
North line of the SWj - 1 200.02
of Section 6 ° - S87o50'03117930081 1
rn
17 • - N
4, 13 C*
INS
N , b garage House o°
171 0 _ a
o c m - 1
LOT 1 . LOT 20
:4 co
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SCALE IN FEET.
0 100 200 300
I
19 -
E ® S7 g 49' S1 W
L
ca FI
g4_
AUG 18.1b8b INTERSTATE LOT AREAS
V) AMES Of 001q/i!!.1
bvktw of Dodo Lot 1 Including Road R/W:
94 OVIX h, 99,958 Sq. Ft.
EGEND 2.29 Acres
Lot 1 Excluding Road R/W:
County Section Monument ;"~~z`y"sue 97,078 Sq. Ft.
• 3/411 Rebar Found 2.23 Acres LEN
a 1" x 24" Iron Pipe Set N 114 Lot 2 Including Road R/W:
weighing 1.68 lbs, per linear foot r 1~1 99,960 Sq. Ft.
2.29 Acres
s- 4 Existing Fence-line t5l 1 , 5C.4, ^ti.
Lot 2 Excluding Road R/W:
,q ~'►x,... ~~y 96,952 Sq. Ft.
2.23 Acres
OWNER •`~BSt~'
Lot 3 Including Road R/W:
Howard Bengston 611,280 Sq. Ft.
Route 1
Baldwin, WI 54002 6~'"6'OWD 14.03 Acres
Lot .3 Excluding Road R/W:
VOLUME 7 PAGE 2012 AU9 18 19$8 605,972 Sq. Ft.
This instrument was drafted by Fran Bleskacek Job No. 88-31 S'a: =D( COUNTY 13.91 Acres
(It" 9 LVW PARKS PLANNING
AND 20NM C &MTff
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 12~'61yl "'1
ROUTE/BOX NUMBER R;" FIRE NO.
CITY/STATE u1~~ ZIP
PROPERTY LOCATION: "1/4 -SL 1/4, Section T ZC N, R 1Z W,
Town of U~/ St. Croix County,
Subdivision Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 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 verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
i
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department 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.
SIGNED
DATE ' 2?' q0
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMENT OF
REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
INDUSTRY, DIVISION
N
LABOR P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 3707
(H63.090) & Chapter 145.045)
LOCATIONS SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
GJ '/4 F '/4 /TZAIR/ tor .moo ~f1 N
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
.5 C v,' Sy00 7i
USE DAT S OBSERVATIONS MADE
NO. BEDRMS : COMMER I L DESCRIPTIO : I R FI NS: PERCOLATION TESTS:
[PeResidence roNew o Replace • -7^ Od 17-2 n_ O fj
RATING: S- Site suitable for system U= Site unsuitable for system 6 0 7 Q d
[CONVENTIONAL: MOUND: GROU ND-PRESSUS STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM•(optional)
[NS ou Zs ir- s ou os u ❑sRU Z
If Percolation Tests are NOT required DESIGN RATE: 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 T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED ES IGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
9 Can r- 5 : 2.1 94 CS Y
o l
B- pAgs, r7Z Ae.9 e, o' 40, 61
B- 92,9 O12 e, >~~1~' 32" ~'l y-,' cSy r • z
9 ,2, l3~ A1,17 e, x'09 /0 'i3.~ •G3'/8 r .
B- 03 9Z'9~ 33 30"'3051A. "
s
0% PERCOLATION TES S
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER aPgei0ES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D PER INCH
P- ,Z,oS Algli
io Z
P- 5 p - 13
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. /110iY7 Sys7~enl - 9YI /
SYSTEM ELEVATION ~✓/fen4fe - 92, 961
I j
i
_ 1 - 7
T_-~
_
.4
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 correct to the best of my knowledge and belief.
NAME print : TESTS WERE COMPLETED ON:
o✓I -
ADDRESS: Dale Z_,
CERTIFICATION NUMBER: PHONE NUMBER optional):
7•s -346
CST SI NATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
I~
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 to scale is preferred. 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 appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, 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 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 COMPI.-FTION.
i
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 - Loamy Sand > Greater Than
*sl Sandy Loam < Less Than
*I - Loam Bn Brown
*sil - Silt Loam BI Black
si - Silt: Gy Gray
*ci - Clay Loam Y Yellow
scl Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot: - Mottles
sc Sandy Clay v"I with
sic - Silty Clay fff few, fine, faint
*c - Clay cc: common, coarse
pt - Peat mm Many, medium
m Muck d - distinct
p - prominent
HWL - High water- level,
Six general soil textures surface water
for liquid waste disposal BIM - Bench Mark
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 pi rrnk 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 5e obtained and posted prior to the start of any construction.
to
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