HomeMy WebLinkAbout018-1008-40-100
t-4
~ x 7d 9 V o 3 m o
N (D O p° C m 3 m
•G
rt p (D V1 I f~D 3 ~ ^ ~
z p IN O
(D p c z o D 2 CD° •
p H d 0
f-n m w 3 N QD
rt co
W Cn l.n r I J p. A O p H O O 7 J OOO 1
o, H. 4-- ~ ga
-P, d 3 .7- a W ~ ~
F•'• N v y o
ON rt O
o O
Ln
0 CO -4 0
Q sr
c N
v I p ~H
F-' O rod'' , m CD w a s o
m O Cl. CID
IW C)
y
LT1~p 3 < l~,l
J Ord'' CD F =1
C C rh coo CO 3 N 0 r- CA
c
n
N N Q
4"- o z O O O !N•
1 n I p c4 Sc,
CL N) H P c
c en
~O C N v o 3 D a° rn
0 0 7 N y CT go ~y
01
m d y tQ.,
O r
CID
m N N
o z03Z O
D a
"wA•
0 CD (D
m l+1
(n
CD
CCD C
C CD CD
m a
w 3
Z CD c6 A 2 n
0
I p
n CL A
I ~
0
W to
m 1 z
3 P
°o " Cl) J
m
I y
N I ?
Op
I N
o m n m
a
p N µ
N 2,10
d ~ C
CD O O.
C1 p
cn m N x
S N
m
Iv
n
N ~
O•
R
O
N
O
.Ar.
0
=3 ~p
CD
p 0 ~y
CD d ~ y
~o
0
N o64
ci ao
c
GL o
a I
i
•a
C
h
a)
O U
N
N O)
O
.p r
N
Q
N
CS -
m
i o
I
N aD
(y
av
ui t o I
ayi v, C
o
o z x
m ~ '2
w
LL C
O_ O N O
C ~ - N N Y
-
N O
Q W C
E
U
m
_ M
d
~ N
i
r d'
fU
W
cn o
rn r € ~ I
IL m
N >
H
i
C
O
Q z C
O
a~i Z rn E z
fA F- r
o
o Cl)
a~ -
N
C O
co o I
7 i
Q'
N
n
N N ~ C
•N d U) L
z m z
O
N Z I I
N d
041
o a~
(0
C 0
a R 0
'n H d n o g °o
a> o G G a c~
y
U) U) U) E Eo
I z
•r ~aaa y
a °
~1 0 0
f% J Co
m E M }
0) _ -p I
j N 0 0 O
I,! t O O 'O E
.-O ml N C 0-
O) ~
r y d Q } !n a3
20 0
C) C ~ r N C
c 04 CO
O O O 7 N V d O 0
r` , M ~ a C N N_
O~ C i O O C
° N
of E a`> CO
aUi H " n
_ Vl
•O 0 0 2 ¢ o z C ri fA
O N E L C L
[ C E
V
`m M ` d
a
• e~a c. m ~ d
`1y E .c c
c
rr~~
~1 A c°~ IL I O U)
` j
Parcel 018-1008-40-100 12/02/2005 09:11 AM
PAGE 1 OF 1
Alt. Parcel 04.29.17.63A 018 - TOWN OF HAMMOND
Current ,X' ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
THOMAS J & MICHELE STRAND O - STRAND, THOMAS J & MICHELE
1772 110TH AVE
HAMMOND WI 54015
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 1772 110TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 20.000 Plat: N/A-NOT AVAILABLE
SEC 4 T29N R17W E1/2 SW SE 20 ACRES Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-29N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
06/26/2003 727543 2290/376 WD
07/23/1997 1033/402 LC
07/23/1997 990/66 LC
07/23/1997 871/349
2005 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 26,000 119,300 145,300 NO
AGRICULTURAL G4 17.000 2,100 0 2,100 NO
UNDEVELOPED G5 1.000 900 0 900 NO
Totals for 2005:
General Property 20.000 29,000 119,300 148,300
Woodland 0.000 0 0
Totals for 2004:
General Property 20.000 29,000 119,300 148,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 117
Specials:
User Special Code Category Amount
010-GARBAGE SPECIAL ASSESSMENT 60.00
Special Assessments Special Charges Delinquent Charges
Total 60.00 0.00 0.00
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. Nme
W Z , E ,'Sec . 4 , T29-R17 (it assigned)
Town of Hammond CONVENTIONAL ❑ ALTERATIVE
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
A OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Julia Achterhof R.R. Hammond, WI 54015
fir
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.. ST REF. PT. ELEV
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Dale E. Hudson 6629 St. C ix 135469
SEPTIC TANK/
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLE V.: WARNING LABEL LOCKING COVER
W~ P S 2;0 7, 7 9oo,, 87 PROVIDED
YES ❑ NO P❑ YES NOF
BEDDING: YGNT DIA.: VM MATL.: HIGH WATER 144UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
C.o • Q , i ALARM: FEET FROM LINE: / I AIR IN ET
❑ YES % NO ❑ YES ❑ NO NEAREST >,Z 6b - l b
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL, BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM 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: MATERIAL 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: 95. '75, a-i- 04 Va., l
LIQUID
WIDTH: LENGTH: TRENCHES- OFNCHES: DISTR. PIPE SPACING: COVER MATERIAL: INSIDE DIA.: # PITS: DEPTH:
BED/TRENCH &1/4 z
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DIST . PIPE DISTR. IPE D QTR. PIP~,~~jMATE qqtty~ NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOV COVE ELEV. INLET: ELEV. END: /)in'_' A PYG PIPE LINE: • r / AIR INLET:
9i ~ . FEET FROM t
~U'~Z3 G,/ [O. S77rI )a% NEAREST - ,Z7 >2
MOUND SYSTEM:
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:
L_ ~ ❑ 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
MBER OF PROPERTY WELL: BUILDING:
PERMANENT MARKERS: OBSERVATION WELLS: 1AREST-
COMMENTS: LINE:
ET FROM
❑ YES ❑ NO ❑ YES ❑ NO
C,/
"
Sketch System on t n in county file for audit.
Reverse Side. SIGNAT E: TITL
SBD-6710 (R. 06/88) h?
d
SANITARY PERMIT APPLICATION
7DILHR In accord with ILHR 83.05, Wis. Adm. Code couNTY~ ~ror~
~ sw,,.vn v
` STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than I S it11c0
8% x 11 inches in size. ❑ Chec if revision 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
C U /I .ct ~i' /C/1-le t'1O S T Z , N, R 11(or W
PROPERTY OWNER'S MAILING ADDRESS LOT # All BLOCK #
CITY, STA E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
❑ State Owned VILLAGE ; ,a?/l i'0/21 61
=L PA' =N QF:
❑ Public ® 1 or 2 Fam. Dwelling--# of bedrooms PARCEL TAX NUMBE ( )
III. BUILDING USE: (If building type is public, check all that apply) 2? 7 1*2-63
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.E] 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 0 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 12. 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) pELEVATION
4450 ,45 ?~S . Z, $4 9195 Feet 191.E Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank do A 1 DOS `~~e=~ S F-1
Lift Pump Tank/Si hon Chamber , I El I F] ~ FE-11
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:
Q/e f . 1/1orl 1~ale r
Plumber's Address (Street, CityyState, Zip Code):
g2 o IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a Zte sue Issuing Agent Signature (No Stamps)
Surcharge Fee)
pproved ❑ Owner Given Initial /i /~j~
A verse Determination "T - P , -1 L/ I ~u
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a 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 renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved I l 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.) 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.
11. 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 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)
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 C"1 '4>
Location of property It" f 1/4, Section , T V N-R 7
Township
Mailing address %2 l12)/',
Address of site
Subdivision name___
Lot number A~X
Previous owner of property
Total size of parcel %c~e S~
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes _ y No
Volume -and Page Number 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 ecorded in the Office of
the County Register of Deeds as Document No. ~S ~'✓~J ; 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 duly recorded in the Office
oft, he County Register of Deeds, as Document No.
gnature of Owner Signature of Co-Owner (If Applicable)
Da,e of Signature Date of Signature
i
Page5b5
No. 200. WARRANTY DEED-To husband and Wife as Joint Tenants.
u. C. MILLER CO., 91LW.9CEE Y59199
This Indenturef Made this 5th. day of August '1952
ust ,1952
NUMBER
between James Joseph Birmingham and Nellie 3irmingham, his wife, of the Town of Hammond, St. .roix County,
235163 ~
'isconsin, parties of the first part,
i
t, and
Myron V. Achterhof and Julia Achterhof, of the same place,
husband and wife, as joint tenants, parties of the second part.
WITNESSETH, That the said part ies of the first part, for and in consideration of the sum of Nine Thousand
(J9000.00) and no/100
Dollars,
to them in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, ha ve given,
granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do give, grant, bargain, sell, remise, release,
alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate situated in the County of
St. Croix, Wisconsin, to-wit:
i
The Northwest quarter of Northeast quarter (iiay of NE4) of Section Nine (9) and the 'Nest Half
of Southeast quarter (Viz of SE4) of L;ectibn Four (11), all, in Township Number Twenty-nine (29)
I
North of Range Number Seventeen (17) West;
(9.90)
(R. S. )
(Can. )
TOGETHER, with all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining; and all the estate,
right, title, interest, claim or demand whatsoever, of the said part ie s of the first part, either in law or equity, either in possession or expectancy of,
in and to the above bargained premises, and their hereditaments and appurtenances.
TO HAVE AND TO HOLD, the said premises as above described with the hereditaments and appurtenances, unto the said parties of the second
part, as joint tenants.
AND THE SAID, James Joseph Birmingham and Nellie Birmingham, his wife,
part ies of the first part, for themselves, their heirs, executors and administrators, do covenant, grant, bargain and
agree to and with the said parties of the second part, and to and with the survivor of them, his or her heirs and assigns, that at the time of the ensealing
i
and delivery of these presents they are well seized of the premises above described, as of a good, sure, perfect
absolute and indefeasible estate of inheritance In the law, in fee simple, and that the same are free and clear from all incumbrances whatever,
i
and that the above bargained premises, in the quiet and peaceable possession of the said parties of the second part, as joint tenants, against all and
every person or persons lawfully claiming the whole or any part thereof they will forever WARRANT AND DEFEND.
IN WITNESS WHEREOF, the said part ies of the first ha ve hereunto set their hands and seals this 5th.
day of August '19 52
Signed, Sealed and Delivered in Presence of James Joseph Birmingham (SEAL)
James Joseph Birmingham
(SEAL)
J. E. Hughes
J. E. Hughes Nellie Birmingham
Eva G. Lynch I Nellie Birmingham (SEAL)
Eva G. Lynch
I ~ J (SEAL)
C-' Q STXF ; OF WISCONSIN,
ss.
County. On this the day of August 19 52
St. Croix 5th. 7
C ~
before me, J. E. Hughes the undersigned officer,
R
Personally appeared James JoseP e, h Birmingham and Nellie Birmingham, his wife known (or satisfactorily proven) to be the
L
v person S whose name S7subscribed to the within instrument and acknowledged that t he y executed the same for the purposes therein contained.
IN WITNESS WHEREOF I hereunto set my hand and official seal.
Received for Record this 3rd. day of J. E. Hughes
October A. D., 1952 , at 2:115 o'clock P. M. J. E. Hughes
l I
(SEAL) Notary Public, St. Croix County, Wis.
David Hope Register of Deeds.
T. ` y My Commission expires November 23 A. D., 19 52
Lucille i,eers Deputy.
H
• to
H
y
ST C- 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
OWNER/BUYER Vt~~iC~ 17C'~~C'✓ ~lla~
ROUTE/BOX NUMBER Fire Number
CI T Y/ S T A T E Z I P
PROPERTY LOCATION: IA.)/2_k, -SY ~4, Section, T l " N, R/_W,
Town of ~/l" j St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix,County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
i
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 veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. -3
0
I/WE, the undersigned, have read the above requirements and agree N
to maintain.the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ro
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County 7.o ng Office within 30 days
of the three year expiration date.
SIGNED
DATE o~ 167
i
St. Croix County Zoning Office
P.O. Box, 98"
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
INDUS
T .Y, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'INDUSTRY, DIVISION LABOR*AN
P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATIO : S SECTION: TOWNSLHIIP/MUNICIPALI Y: LOT NO.: BLK. N O.: SUBDIVISION NAME:
ITzp11 /71 (or W 1-l' a 7m onl NA
COUNTY: OWNER'S BUYER'S NAME: MAILIN ADDRESS:
r., ,x
LJm O . .
USr - DATES BSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTIO PROFILE S:
ERCOLATION
TESTS:
I Residence ❑New Replace l 9o 1/-/7-7(/
RATING: S- Site suitable for system U= Site unsuitable for system l !O 7 CONNVnVE~~++NTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING TANK: RECOMMENDED
SYSTEM: (optio al)
J~JJ ❑U OS ❑U [:]U ❑S &U ❑S ~U C nv r'o✓~
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 TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHf*. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.Y
B- / 7,2' 99.35 goe } 7' Z ~ .Z,Z ~ls•' • 1,5 ,6, s:~• "Bri S
B- Z to IG, 8 •~l n lv /~i ,Q' ,S' s; • ,2.33
B- 3 ~ • YZ 97.97" e • ~Z ,1'9 hr - - 7 "R. . rz e.
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER t ea@E9• AFTERSWELLING INTERVAL-MIN.- PERIOD 1 PE I 2 P R PER INCH
P_ Z „
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 -f- !
i
TN
I
i
I
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:
>a le so 21 - / 7 - Z2
Io
ADDRESS: za CERTIFICATION NUMBER: PHONE NUMBER (optional):
7 Gam', spa/Z 3 7 is -G -3600
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRI)CTIONS FOR COMPLETING FORM 115 SBD 6355
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 elates, 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 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 - Loamy Sand > Greater Than
*sl - Sandy Loam < - Less Than
*1 - Loam Bn - Brown
*sil - Silt Loam BI Black
si - Silt 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 fff few, fine, faint
*c - Clay cc - common, coarse
pt - Peat mm - Many, medium
rn - Muck d distinct
p - prominent
HWL - High water level,
Six general soil textures surface water
for liquid waste disposal SM - Bench Mark
VRP Vertical Reference Point
I
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 pf,rmit issuance. A complete set of plans for the private
sewage systern and a permii application n'ust he s.zirmitte<ii to o [)riatel local authority in order to
obtain a permit. The sanitary permit roust tw obtaflred and pasted prior to the start of any construction.
PC,, 7w, r a M
/~r~morlp~J G(/i.
/Y mi n l F;'ll
rove
n o
/o Z Z a `j o f o s o o v A .site.
Q1- C
993 % ~
o n u ty ~ 4 i
OZ - 98051 A~ a g r eQ Gl k 4P,e-
U
133 - 97, 97 • Per- o rate-d w y SE
pipe
13enj Mart< P top o~ ~z9N Rr?Id
Cement 516L at nor 7%
Shed
Fsedt She
18'-> 4 36
I ve.~~ zo'
83
I ~ Qo 0
9y5°
z~ Drain
I Opt
0 13Z-
p z-r'
1 I zs~ Field
!Q
o S
Sepfc s' 8Q D2►~UIeS ~Joi'g
I I /DO~i ~l ~.Z °lo No /e S
3 g pa 2~enof e S Perc. N°•
I ~ Exisf%n9 ~o~CS
/ !C/ouSC
l1
$6'5/ ~rc~wn 13y:
I ~ I M' P 6G 29
es't' 3AJ i 3
Sca~e / 5~0