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Form -STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER iA -r k 7 a r R TOWNSHIP t7 k 1250 ) SEC. ~ T ~N-R~W
ADDRESS q 8j ST. CROIX COUNTY, WISCONSIN
SUBDIVISION #9 LOT N LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
E1-~
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000 GA15~=P'
rose
_ (~rri 5~ alt,-- ► "
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ~w Tie -t
Elevation of vertical reference point: _190,_0 Proposed slope at site: p
SEPTIC TANK: Manufacturer: Liquid Capacity: 60 C
-Number of rings used:_ Tank manhole cover elevation: 917. 3 P~
Tank Inlet Elevation:__._j 3 , Tank Outlet Elevation:
Number of feet from nearest Road: Front, Side,Q Rear, O 9 5 feet
From nearest-property line Front ,aide 10 Rear, O 9 s feet
Number of feet from: well Zo , building: j q
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
i
1
PUMP CHAMBER
Manufacturer: Liquid Capacity:
'Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property lines`. Front, O Side, O Rear, p Ft.__
r
'Number of feet from well:
Number of feet from building:_
(Include distances on plot plan).
SOIL ABSORPTION • SYSTEM /
Bed • Trench: v
~C3
Width: Length. .-Number of Lines. Area Built::no o
Fill.depth to top of pipe: 40
Numbs m nearest property line: Front, Side, Rear, Tt.:
Number of feet f o ~0
~ ~ O O
(Number of feet from well: HZ
N ber of feet from building: )6.e,
(Include di lances on plot plan). Sys71, % 6L. q1 J-1- _ KZ,23
d~~i.-~~dT~p P P~ ~L
SEEPAGE PIT ~
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box Q or distribution box O been used on any of the above soil
absorbtion sytems? (C'eck one).
HOLDING TANK
Manufacturer: Capacity:
Number of'.rings used:' Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from.nearest road:
Alarm Manufacturer:
2
Inspector:.
Dated.:'- May D, 90 Plumber ,on job:
M
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License Number : Mn
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BDIVISION
4_ABOR r HUMAN RELATIONS
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
9 ISO 153 07 State Plan I.D. Number:
fi ,1~ , S~eC .15,T29-R19 El CONVENTIONAL El ALTERATIVE (If assigned)
Town of Hudson
' C El Holding Tank El In-Ground Pressure El Mound
Rd.
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Ruth Katner 8C Rd A Hudson, WI 54016 -1 W o~000
BENCH MARK .t(Perm an nt reference point) DESCRIBE IF DIFFERENT FROM PLAN: REP.. P 1.. bLEV.:CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: anitary Permit Number:
Carl P. Heise 3378 St. i
SEPTIC ANK/HOLDING TANK:
TFAC URER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
~y PROVIDED PROVIDED:
olJ q i 7 b B ~ES ❑ NO ❑ YES .2MO
BED ING: VENT DIA.: VENT MAIL;- I HIGH WATER NUMBER OF ROAD: PROPERTY WELL: TI ING: VENT TO FRESH
ALARM: FEET FROM LINES, / AIR INLET:
❑ YES NO YES O NEAREST ~ ~
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SI ON AN CTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES El NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIC, L: M PER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN EE FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO EAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FO E ENGTH: 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:
BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS lob n
GRAVEL DEPTH FILL DE TH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. D TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
J
BELOW PIPES: ABOVE 'OVER: INIL 17S PIP _ FEET FROM LINE: ! AIR IN~TET
l/~_ tollJt NEAREST ~V t Z f J1 /
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: I 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 a MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
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: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
col
A
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4
C
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNAT E: TITLE:
SBD-6710 (R. 06/88)'' ~7f
SANITARY PERMIT APPLICATION
•11 fILNR In accord with ILHR 83.05, Wis. Adm. Code COON
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8% x 11 inches in size. 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 PRO.P%ERTY LOCATION
Rv,-r a-r*c r' VV -'/a pA Y4, S 15 T ~ N, R L C I X(Or)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE CC ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
w -S 1-64,3 to Zl s 3P6-a23 N
II. TYPE OF BUILDING: (Check one El CITY u~S NEAREST ROAD
State Owned ❑ VILLAGE : H
Q _
❑ Public M 1 or 2 Fam. Dwelling-# of bedrooms 3 PRE TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) 15- Z T- v7 1
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 5.0 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 ,K Seepage Trench 22 El 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
S ® REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
95 500 D , & Feet 5 7-Feet
Vll. 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 structed
Septic Tank or Holdin Tank ) D 0 ) O + I W CIE ft.:~ Pd I F1 Q I 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: (No Stamps) M Business Phone Number:
on-se ` , 3,3? 6
Plumber's Address (Street, City, State, Zip Code):
1049 S. % . s-1, 1, 54o2
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate slue Issuing gent Signature (No sta s)
Surcharge Fee)
pp roved ❑ Owner Given initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
L_ i
SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & 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 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 ;I years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 64)8-266-3815.
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; (Jose 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.
S8D4M8 (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. Y
Location of Property VV F~ YV -2 3x, Section T Q N-R_ W
Township tt ~~Sa ►~J
Mailing Address q 6i a
Address of Site $ arr c
Subdivision Name h; o
Lot Number ifti A.
Previous Owner of Property
v
Total Size of Parcel ) Q 4
Date Parcel was Created
Are all corners and lot lines identifiable? Yes i-~ No
Is this property being developed for resale (spec house) ? Yes No
Volume
6 and Page Number 7 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (we) centi.6y that att s.tatemen a on .thi6 for ane tAue .to -the be,6t o6 my (oun)
knowledge; .that I (we) am (cute) .the ownekk the pnopenty de.6c4ibed in xhiA
.in6avnation 6oAm, by viAtue o6 a wamanty deed keconded in the O66.ice o6 the
County RegiA ten. o6 Veed6 a,6 Vocument No. S 0 z.- ; and that I (we) pne6 entty
own the pupos ed .6 to bon the sewage di apo.6 b y6 em (on I (we) have obtained an
easement, to nun with the above d6ch ibed pupen ty, bon the con.6fiauct i.on o6 6a.id
system, and the same has been duty neconded in the 066.ice o6 the County RegiAten o6
Veeda, ab Document No. -Z7,
o
SIGNATURE OP OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
JCS /~a
DATE SI DATE SIGNED
QUIT CLAIM DEED
I DOCUMENT NO STATE OF WISCONSIN-FORM 13
THIS $?AM RI'=VW FOR RMRDD(G DATA
275Oil2
REGISTErs OF1-1c-::
THIS INDENTURE, Made by Ralph L. Katner and Ruth C. ST. CRCIX CU.."f:
Katnerp-his Wife Recd for Record this 21st
day of---Januar P.I:.
grantor E_ of St.✓ Croix County, Wisconsin, hereby quit-claims ~dl•
to R911Pb L a n r and Ruth C. Katner, husband and wife at_____ 9:DII-- ter
an joint tenants, David- H4P~
' ' - Register of C
i
grantee g RETURN TO
of St (!rp j x County, Wisconsin, for the sum of
On- Do11gr ar,d o.h r rcood and value consideration - - - - -
the following tract of land in St. _Croix r County, State of Wisconsin;
I, The Southeast Quarter of Southwest Quarter and Southwest Quarter of Southeast
Quarter of Section 10 and Northwest Quarter of Northeast Quarter and North
One-half of Northwest Quarter of Section 15, Township 29 North, Range 19 West,
except Commencing 2 rods North and 2 rods West of Southeast, corner of Northwest
Quarter of Northwest Quarter of Laid Section 15; thence
North 10 rods; thence.West 8 rods;-thence South 10 rods; thence East 8 rods
to point of beginning. Subject to the railroad right-of-way of record.
i
The purpose of this deed is to create a joint tenancy in the parties hereto, who
are husband and wife.
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IN WITNESS WHEREOF, the said grantor 6 he a hereunto set - their ____hand a -and seal e -_-this _ 24th-_
day of January , A. D„ 19 n C/
SIGN / D SEALED IN PRESENCE OF & ~ /l 7k/_L_ (SEAL)
Rs, ph_~r~. Ka.#, eer-~--
-~~I c_. (SEAL)
ohn B._Heywood Ruth C. Katner
'L ,~J e (SEAL)
Carol McDaniel -(SEAL)
STATE OF WISCONSIN,
St. Croix }es.
• County. JJJ
Personally came'before me, this -20th day of January A. D., 19 64_
the above namod alvh L. Katner_and Ruth C Katner
' to meytgbwpp• t tlfbon Rvho executed the foregoing instrument and acknowledged th ma. T
] 1A
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~ k,*J , ~tti ~ trrf~_
John D. Heywoo
1 ,.1asi ` ~L NOTARY -
~~•L~ etrtle1fki~j..N DEAL
This td(d t Notary Public St.. Croix
F County, Wis.
John D. He ood Attorney at Law, Hudson, Wis My CommfesionXRN1hM (Is) Permanent
V (Sectloo 69.81 (1) of the Wisconsin statutes -provides that ap Instruments yyyheeee eaorded ve ptalnly printed or gpewrltten thereon the
news, of the Aranton, aragtes,, witnesses and notary). 817 ' SUIT CLAIM DEED-STATIR OF WISCONSIN, FOAM NO. 13 VOL 41111 PACE
R. C. MILLER 60., YILWAUl[S,
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER DYER C w-t~ /L rt T w c r
ROUTE/BOX NUMBER ~'1 f FIRE NO.
CITY/STATE [WS:; nb is ,674 0i zip S40
PROPERTY LOCATION: FV 1/4 1/4, Section , T_~? _N, R__W,
Town of Lt I's St. Croix County,
Subdivision 1N 9 , Lot No. JV A- .
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.Croix County Zoning Office: within
30 days of the three year expiration date.
SIGNED
DATE a-v
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
DERARTMENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IN iiSTRM, DIVISION
LABOR AND` PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069
HUMAN RELATIONS
(H63.090) & Chapter 145,045)
LOCATION: SECTION: WNSHIP MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
1 / 15 T29N/R I (o YV NU NA
COUNTY: WNER' UYER-S NAME: IMRAlL( G ADDRESS:
,I g f4kjs t,.~ 5 0►
ST ~Roi R 981 C.O.
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: C7VA CIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
R Residence ❑ New R eplace C, 9= p 0 5_ 7_ O
RATING: S= Site suitable for system U= Site unsuitable for system 7
CONVENTIONAL: IMOUND: ~~++IN-GR~~OqUND-PRESSURE; rYESTES M-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional)
®S ❑U IJJJ S ❑U ®U ❑S Inj 7r-01"Cb 5x 00
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: C I& Floodplain, indicate Floodplain elevation: IV h
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- a 0-19 I2L SiI 0-:S4 L1-f3r► S;L 34-42 L-r13n Scl w/cob
86 15.22 NoNr-- 42-54 RAGPI tis"seS w Go►o - r
0- q tats.( 9-21 "LT(3#k S;1 21-28 L. On S;) w/oeb
B- Z qd gq.92 NONE 25-38 R16h w .-90 51- r
„ 0-12 Gat s; 12-21 LTJ13-i 5:1 z1-25 LT (3K S; l u1c,ub
B-3 42 9 3.2 2 NU N S 2s-9 2&O-%CS w co 45-4
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 PERIOD 2 P R PER INCH
I
P_ I g'~ t ~Z ri rtW a94 i I-esj
_C t Z +rs
P- 2 3G" w L Z
G
P_ <Z1
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 .
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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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
69 S M 5T 1R- 4_r V~kks -5402-2- 1713- 25-2175
CST SIGNATP:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
• ~ r
INSTRUCTIONS FOR COMPLETING FORM 115 - SBO - 6395
To be complete and accurate sail test, your retort must ir)clude:
1. C m !:-al description;
2. ion rust clearly in( rether this is a residence or commercial I
1 iMr- : -ber of bedroon nmercial use planned;
4. Is cement
5. Comt - .7!1ity ratir, I A SITE IS SUITABLE FOR A HC` TANK ONLY IF ALL
OTHER v ARE RU LC -T ERASED ON SOIL CONDITIONS;
6. PL-ASE bbreviatio here for variting profile descriptions and completing the plot plan;
7. -_i3LE diagram ac 1y locating yo,{r 1-st ,ations. Drawing to scale is preferred. A
he used it .
S. mark a elevatio i -are clearly shows re permanent,
9, r_ e ho; . ; o dates, I,r Hood plain data, tent exemp
1(1. if 91evatioO does not glace N.A. ire piupriate box;
11. Si t ~a address and your cer ion number;
12. M d dis as required. ALL SC TESTS MUST LED WITH THE
'Y''.JITHIN DAYS OF COMPLETION,
ABBBEVI. _ ._3 FOR CERT... ~ .SOIL TESTERS
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v ~~T: cam` P:Ly Approved Vent Cap For
Minimm 12" Above )<,4
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Synthetic Covering
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6" Aggregate 0
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