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HomeMy WebLinkAbout016-1025-95-100 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP,-J _ N SECTION T I~l Z2 W, (Q ~ ADDRESS_ V Un" ST. CROIX COUNTY WISCONSIN t~~tt.9CbD r ~ . SUBDIVISION LOT LOT SIZEJC~S'L PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a t1 !S 1:5- °70 1 N 9~' so KGs ~k " d T-1 S ' ICATE NORTH ARROW BENCHMARK: Elevation and descript~o: a Alternate benchmark C/, S/y SEPTIC TANK:Manufacturer: ~i~~cST(R~ (i~tEiquid cap.- Rings used:Manhole cover elev:SFinal grade elev:3s' Tank inlet elev.: 26 s Tank outlet elev. No. of feet from nearest road:Front, Side Rear Ft. From nearest prop. line:Front , Side_K, Rear Ft. U No. of feet from: Well Building:---/ (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front-, Side_, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: )C Seepage Pit: Width: -Length S-6 ` Number of Lines: Z Area Built Q 49S Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: te7 t No. feet from nearest prop. line:Front , Side Rear_X Ft._~e- No. feet from well:_LL~_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 : .J i rye Ti~DYYIInSd~J DATE : o PLUMBER ON JOB : LICENSE NUMBER: ln/' Z /9 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: Se4,NW4iSec.12,T30-R15 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Glenwood ❑ Hol ing Tank ❑ In-Ground Pressure ❑ Mound NAM OF PERMIT HOLDER:. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Q Rnorpr R ~Rt nwood CitV_ WT 0 BENCH MARK (Permanent reference ro- t) DESCRIBE IF DIFFERENT F OM PLAN: REF. PT. L V.: CST REF. PT. EL ~O o 0 . Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: SEPTIC TANK/ 6•y5~ ankoLeG~9 y, Z?' 44 MANUFACTURER: LIQUID CAPACITY: TANK INLET V.: TANK OUTLE WAR N LABEL LOCK G COV R / n PROVIDED: PROVIDED: y~ l~DG !.V J` e- ca-s- YES ❑ NO ❑ YES NO BEDDING: VEM~DIA MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT ToF ESH G .3 ~7 ALARM: FEET FROM LINE: AIR INL ❑ YES NO ❑ YES NO NEAREST -11111- > v MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: P VIDED: ❑ YES ❑ NO YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY 7~7 ING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YE NEAREST ~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LEN TERIAL 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: BED/TRENCH WIDTH: I LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: IAL: PIT DEPTH: DIMENSIONS S Sd ! c;z GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTFFjj, PIPE MAT RI L: NO. TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLETELEV. END•! ec/"/iCft:/g IPES: FEET FROM LINE: AIR INLET: fit 6X NEAREST e~, MOUND SYSTEM: 9, 5-4 Mound site plowed perpendicu C eck 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 TEXTUR : PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/ BED DDEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYS M: BED/TRENCH WIDTH: LENGTH: RS.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TR HES: DIMENSIONS -N, J MANIFOLD PUMP MANIFOLD ISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & ARKING: ELEVATION AND ELEV.: ELEV.: DIA.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: OVER MATERIAL: VERTICAL RESPONDS TO INFORMATION PLANS , -APPROVED ❑ YES ❑ NO ❑ YES ❑ NO MBER OF PROPERTY WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: iAREST- COMMENTS: ET FROM LINE: ,07 (i ❑ YES ❑ NO ❑ YES ❑ NO l off r,~ r 01 e in in county file for audit. Sketch System on K Reverse Side. d~' _ SIGN URE: TITLE: / SBD-6710 (R. 06/88 / l a 1. 7-DILHR SANITARY PERMIT APPLICATION couN In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMI -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 G 7 8% x 11 inches in size. c ec i re ision pre sous 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 L TON S r ~/a S 12- T.3O, N, R l c~~ E (or) rq (1 PRO,,R ,T Y 'S MAILING ADDRESS LOT # BLOCK # C 11Y, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~~u1do ,j], II. TYPE OF BUILDI (Check one CITY NE BEST ROAD . ) State Owned ❑ VILLAGE ~ , H ❑ Public K1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMB Ill. BUILDING USE: (If building type is public, check all that apply) 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. X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 r 7., Feet . 0 Feet VII. TANK CAPACITY Site in ailons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank t liClt+ t~nft mt Lift Pump Tank/Si hon Chamber El El E1 F-1 I F1 Ej 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' ignatur : (No Stamps) PRSW No.: Business Phone Number: ,,i 06-74~p_ P um er's Address (Are t, City, State, Zip Code IX. CO NTY/DEPARTMENT USE ONLY S m ❑ Disapproved Sanitary Permit Fee (Includes Groundwater =Datelssued =_4 Sign ture No Surcharge Fee) Approved El Owner Given Initial 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 & Buildings Division, Owner, Plumber i y 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 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 maintailned. 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- a water contamination investigations and establishment of standards. SBD-6398 (R.11/88) i 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 ownet/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 ary=:!1 Location of property 6 1/9 AAJ _1/4, Section / Z , T~j O N-R Township eo t r-S Mailing address %Z A Z C D (11, ~~D>3 Address of site Subdivision name Lot number Previous owner of property 4 n,..-. n1 A rt A" 4-- ,-Y.=7Z, Total size of parcel ~~o D /4e12 CS Date parcel was created Z-2 S Its- G Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes X_No Volume V27 and Page Number 6 140 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. 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. -2 T 6 L -2.8' ; 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 du y recorded in the Office of a County Register of Deeds, as Document No. 2-2 ~ Si ature o Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 21eic 0 zl J ~ U rq4: e'LN ROUTE/BOX NUMBER FIRE NO. CITY/STATE L~~z=-r~ct~ ~ l r ~-Z~ /,(Je c ZIP 5YO13 PROPERTY LOCATION: C~ 1/4 114, Section T_:~Q N, R_ W, Town of c'- jUJ6o-,> , 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/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.Croi ounty Zoning Office within 30 days of the three year expiration date. SIGNE DATE 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 P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: OWNSH LOT NO.: BLK. NO.: SUBDIVISION NAME: 4 &A/ 14 l 1T3 oN/R 1,sX- COY_ D OWNER'S/BUYER'S NAME: MA LI G ADDRE USE • C,+'~/ T DATES OBSERVATIONS MADE l NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: IPERCOLATION TESTS: X Residence New ❑ Replace ~7 r1 O 9~ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHIETA : RECOMMENDED SYSTEM: (optional) ~ C1U EISM MS DU El S~ If Percolati on Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(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 EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 8Y Q-2A'0AAy_St4 2-A t ! B- > c~ I / O yo y - B- 3 1'6' B- Ica 32- B- 6 /,oo r S B- 6 1a mil/ > 6 _ - 6 OO zVoiVg >6e ERCOLATION TESTS a 6 ..2 XX TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INGKES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R OD3 PER INCH P- P- P- P_ -1 P- PLOT P- 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 surf elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION s N 30©' , I, the undersigned, hereby certify that the soil tests reported on A is form ere 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. int): TEST ERE COMPLETED ON: NAME 11 ADD EESSS: A~ a CER IFICATION NUMBER: PHONE NUMBER (optional): ;Z 16S_,16 2 _5'r 3 6 V4 C NATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - I` SUCTION R COMPLETING FORM 115 - ; To crti to , ,at; yr l _ Cornplet, ription; 2. The use Er ,t cik w ly i whether this is a ~ ~'ice orcornmerc€al project; . P0, AX I r of bedro commercial use 4. k this acement s 5 Cornpl~ r il,y rating I A SITE IS Si ?,LE FOP, 3 TAF _Y IF ALL 01-HER ARE RULE ET BASED C" 6, PLE. f F )bl eviations < here for ; rr~. le u-- - , _ <ons anc comp t1g the plot plan; 7. MA , LE diagram a. =y hocati t _t lc:~c Otis Drawing to preferred. A e c and =al elevation nt we c re permanent; e all <;sar c . "-ic: boxes 'ates, names, s, flood p,din ( _ a, I air test exemp- appropri ; 10, I~ ")e information (such as flood r levation) dogs place N,A. in the ar ;w-iat:e box; 11. Sign the -form and place your cur rer ,idress and'your ce Ei number: 72. Make legible copies and distribUtC as required. ALL 5t ESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETIC.. A_ iEVIATIO FOR CFRTIF' 'IL T1 Soil Separates and Textures r Symbols ct Ston"~ €ovee 10 BR 'rack cob Cobble (3 - 13") SS gr Gray=el {under 3") LS ~nt Sand HGVV High fa, } _r e Sand F Percolation n "_;m Sand . Well Sand nd _ 1r) < Less T1 an E L; y Y caw Lowil y Loam } ; ;l CC i _ . pt men- I' P ".4 tJ3C t, l1"S €;spoSal F Ws,ce Poinr TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The count, or the Department may request verification of this soil test in the field prior to permit issuance. A comr,c set of plans for the private sewage system and a permit application must be submitted to the approp= = local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to tl-., start of any construction, DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 6 INDUSTRY, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: 1/ 1/ /T N/R E (or► W COUNTY: OW R'S/BUYER'S NAME: MAILING ADDRESS: E cST ~4~ USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPT ONS: IF-E-R-COTEATION TESTS: I ❑Residence ❑New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑ S ❑u ❑ S ❑u ❑ S ❑u ❑ S ❑u ❑ S ❑u DESIGN RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(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 EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- B- B- B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERI D PER INCH P- P- 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 loc{~tJ. n on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. K4 OL9f8 45T,9ys,ayRY L/ACE ,4,., r v SYSTEM ELEVATION Z % F . E E N 3 , X90 ~~3~~~ 3 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. TESTS WERE COMPLETED ON: NAM rint►: 7':~06 ~ ADDRESS: /C CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - INSTRUCTIONS FOR COMPLETING . 115 - S IB ' 60 x,,i.'ate yow reAult i?a 1 Corr 2. The use must clearly i- - hether is a residence oacommercial project; 3. MAXII_' nber of bedrr +r -,,rnr planned; 4, Is 0 replacement s~ 1; h. Comple! ty ratii A SITE IS SUITAB A HOLDING TA IF ALL OTHER SYS~ L'_1S ARE RULE OUT BASED Gl' --)[L CO[. ',ITIONS; S_ PLEASE use t1,,: attk~reviations s.,uuxn here for wr,ti profile di~scriptions and r-, ng the plot plan; 7, MAKE A LEGIBLE diagram accurately locat tc>A locations. Dra,nrir,, ~ sz.is preferred. A p,-;rate sheet may be . si-,A if desired; sr re your ` and vertical elevation r int are c 'a' permanent; 9. i 3_e all appr'~i , id'tP, boxes as to dates, mrn?es, au c--, plain Et" ' tent eXemp- ,f :appropriate; 10, I` t`:e information (such as flood plain, elevation) does not place N box; 11. Sign the form and place your current address and your certific iK'n mule' 12. Make legible copies and distribute as required, ALL SOIL TESTS M ' BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. A _.IEVI . It ; r FOR CE3TIi" x .AIL T Soil Separates and Textures Other Symbols t S .r 10") crab 0.. (3 - 10") S asta gr - Gr ider 3`) t yes.:; " Sand 11 High Groc - t mrse Sand F Percola um Sand - Well Sand 3 i S, y I ~arxr Less are 1 Loam Bn Brown I 3iit Loam R Black si slit Gy Gray cl oarn y yeilow, s y Loam - sari y Loam rxJt S y tJ, sic y Jay ff; rat t c cc p- mill - . ri7 ac..n €1 p X Sr l texti.ires d 7,- V,iP ;;ticzai Wo, re Paint A 'TO THE OWNER: This soil test report is the first: step in securing a sanitary permit. The county orthe Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private a permit application must he submitted to the appropriate local authority in order to obtain a p it, sa-tary permit must be obtained and posted prior to the start of any construction. 30 .tf/ fL fs`c J i~ z -J, ~/rl tZ, -Bv c6:~d ft>t,c` Wfs. s9Y7 2 s-- ~l-ego L-rz, 04or t4 7q.0 at~ 13-15- t7_ - y - A~ . x / /r7, Al O2iQ (l rZ 11.6' P'as~r-rr] C(f~ n f 'C~'c ate, ~ ~-1:5- )01 i s ~ 6AA.5, Coo ~r r_S71~ 3 3c~:' -gyp s 3 a ,,-I. A s/6s ; I w