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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
4OWNER'_ TOWNSHIP 4GdSc~" SEC.' T N-R W •
ADDRESS f„'ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT 1'* ` LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 12HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
• C~WTJIAL we It
J~5 r►Jr,~ '~a e l 4c
_ a 5ys•k., c rcc,Q•
n 2,1 j-0
• . • .I a j•
Al.
INDICATE NORTH
. _ _ . _ . ~ ! ~ i ARROW
BENCHMARK: Describe the vertical reference point used { ors 5?
Elevation of vertical reference point: 140 Proposed slope at site: ! r`j
t SEPTIC TANKS Manufacturers- __f Liquid Capacity: 124o
•••'•l•Numbet of rings used: 'Tank manhole cover elevation:
• Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: I
Front 10 Side„ Rear, O f 6. feet
• From nearest-property line : • Front,oSide10Rear,0 ~3 7 feet
Number of feet from: well `d , building:
(Include this information of..the above plot plsn)( 2 reference dimensions to septic tank)
SEE, REVERSE SIDE L
PUMP CHAFER
Manufacturer: Liquid Capacity: Aoo
Pump Model: NAT Pump/Siphon Manufacturer: TQ•?e l/tr Pump Size
Elevation of inlet: Bottom of tank elevations
Pump off switch elevation: Gallons per cycle: 15!(
Alarm Manufacturer: Zoe//{r Alarm Switch Type: rztlc&_eN
Number of feet from nearest property line:'. Front, O Side, O Rear, ® Ft.
'Number of feet from well: -7j
Number of feet from building:
(Include distances.on plot plan).
SOIL ABSORPTION•SYSTEH
Bdd: Trench:
Width: S ~ Lenith: ( .-Number of Lines: 2 Area Built:
Fill depth to top of pipe: 1_2 V.
Number of feet f,om nearest property line: Front, O Side, ® Rear,O Yt.~
4Number of feet from well: (o/ .
N 'ber of feet from building: -:716
(Include di lances on plot plan).
SEEPAGE PIT
Size: A Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
t
Has either a drop box ® or dint*ibution box 0 been used on any of the above soil
i
absorbtion sytems? (C eck one).
HOLDING TANK
Manufacturer: ~V Capacity:
Elevation of bottom of tank:
Number of '.rings Used:.
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
' I
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Io Plumber on job:
Dated.
License Number:
3/84:nij
. bEPARTMENT 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:
SW 4f NW A4 i Sec. 17 , T29-R19 assigned)
COVENTIONAL El ALTERATIVE
Town of Hudson ❑
El Holding Tank El In-Ground Pressure Mound
NAME OF P RMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI D T
I
,O
BENCH M ;X, (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: R!F;E E . PT. ELEV.:
Y.®• d ~
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Roger Timm 3224 St. Croix 135474
SEPTIC TANK/ f el
MANUFACTURER: LIQ ID ITY: TANK INLE TANK OUTL LEV.~ ARNING LABEL LOCKING COVER
OVIDED: PROVIDED:
ES ❑ NO 14U
BEDIDING VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: /PROPERTY WELL: BUILDING: VENT TO FRESH
'ARM: LINE: / AIF3',NLFT:
FEET FROM
❑ NO L/ /n Ei-YES rVA 0 NEAREST I
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CA I Te PUMP MODEL: PUMP/SIP41C7d MANUFACTURER: WARNING LABEL" LOCKING OVER
LlcSle Q,1~S ❑ YES I,Z4 NO 9 YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMER OF PROPE RT WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN EIT! FROM LINE: AIR INLET:
PUMP ON AND OFF YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at th epth of plowing FORCE LENGTH: I DIAMETER: M TEBIAALLANgyCKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN A I/ c $/0
the soil is dry enough to continue.
CONVENTIONAL SYSTE
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH /KIN TRENCHES: MATERIALEFEE . DEPTH:
DIMENSIONS IU 94
12
GRAVEL-- PTH FILL DEPTH DIST PIPE DISTR. PIPE DISTR. PIP MATERIj~L: NO. D STRER OF PROPERTY WELL: BUILDING : ~VEjR NT TO FRESH
BELOW PIPES: ABOVE CO ER: ELEV. INLET: E/L~EV. END: yHs PIPES: ROM LINE: / INLET: 40
J~f ST ' 5
MOUND SYSTEM: ,1%
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:
1P ~ ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
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: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST---*
~ O
/e o~'~occr»p ' ~CO~ ; p~C~pd att~! `C
U~, heel s.1 x ' . E 1U d s ' r 81'
et in in county file for audit.
Sketch System on ~J
Reverse Side. SIGNAT E: TITLE:
SBD-6710 (R. 06/88)
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code Cou
~v
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ~c^ 7
8% x 11 inches in size. ❑ cnl6lr( revision to pre lous 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
`err Le /3 &In %4 NW %4, S /`7 T Q N, R /7 E (or)
PROPERTY N R'S,MAILING ADDRESS LOT # BLOCK #
~ nr- WA
617 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER
CITY NEARES R D
II. TYPE OF BUILDING: (Check one) 11 State Owned VILLAGE : pj, I 6~
❑ Public 91 or 2 Fam. Dwelling-# of bedrooms
Ill. BUILDING USE: (If building type is public, check all that apply)
6 "zo - jQ 373
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) 1.0 New 2. Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System PSystem 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 6 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
4c REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
~o ~~/,f 5/6 Feet Feet
VII. TANK CAPACITY Site
INFORMATION in as Ions Total # of Manufacturer's Prefab. Fiber- Exper.
New xistin Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank / c, Ej F1 - Lift Pump Tank/Si hon Chamber dr0 / e
o
El El El 1:1
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' Signature: (No Stamps) MP/MPRSw ~ Business Phone Number:
Plumbs s Ad s (Street, City, State, Zip Code):
IX: COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing gent Signatur (No Sta
/ A
Approved El Owner Given Initial Surcharge Fee)
~ /✓~l
Adverse Determin i n
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
98 (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 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 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'f2 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
his application form is to be completed in full and signdd by the owner(s) of the
roperty being developed. Any inadequacies will only result in delays of the permit
esuance. Should this development be intended for resale by owner/contractor, ("spec
Ouse"), then a second form should be retained and completed when the property is
old and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
er of Property
Location of Property cz k ~ 1x, Section _/7 T ~ N-R 1 W
Township C
bailing Address q-74 r*, Q14p_ ~ L u n f
H y 4 4z lnr U ~p
Address of Site S A ~e
Subdivision Name _ }7 0 ~ e}r--
Lot Number
Previous Owner of Property r~ V C
Total Size of Parcel .E 4c
Date Parcel was Created
Are all corners and lot lines identifiable? >C Yea No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Wartanty 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 (Wd cv-)W6y that aCC bta.temen ,6 on tlw or ace tAue to .the best o6 my (ouh)
hncwtedge; .that I (we) an (ahe) the own(n6 o6 the pnopeA.ty deAcni.bed in this
.imAoimation down, by v.cA.tue o6 a wavcanty deed neconded in the 066ice o6 the
Cohn(y RegiAten o6 Veede as Voeument No. ; and that I (We) pneaentty
c.un We p4opoacd site 6oh- .the 'Selvage dizpoe bys em (on I (we) have obtained an
r"er*en.t, to Run with tile above deAcA,i.bed pnopeAty, bon the eonztAucti.on o6 aaid
aystcm, and the game ha.e been duty neconded -In the 066tee o6 the County Reg.i.e.teA o6
Vetde, as Voement No. )
SIGNATURE 0 OWNER SIG TURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
State of Wisconsin
ss '
County of St. Croix
THE ST. CROIX COUNTY ABSTRACT COMPANY hereby certifies that the foregoing abstract consisting
of entries No. 97 to 103 , both inclusive, is a correct abstract of title since
April 2, 1980 at 2: 30 o'clock in the P._ M. of lands described in
Caption No 97 hereof, to-wit:
Part of W1/2 of NW'/. of Section 17-29-19 descibed as follows:
Same land and easement as shown in the Caption.
That, for the period covered by this certificate, said abstract correctly shows all matters affecting
or relating to the said title which are recorded or filed for record in the office of the Register of Deeds
of said County, including Federal Tax Liens and Old Age Assistance Liens filed therein against the parties
listed below.
For the period covered by this certificate, except as shown by this abstract, there are no unsatis-
fied mechanic or material liens affecting title to such lands docketed in the office of the Clerk of Courts
in said county for the past two years.
That, except as shown in this abstract, there are no unsatisfied judgments, including delinquent In-
come Taxes, docketed in the office of the Clerk of Courts in said County within the past ten years, as and
against the following named persons which affects the title to the real estate above described to-wit:
Terry G. Domino
or
Barbara J. Domino.
That for the period covered by this certificate, all instruments appearing in this abstract contain the
necessary number of witnesses and acknowledgments unless otherwise noted.
We further certify that for the period covered by this certificate that we have carefully examined
the records in the office of the County Treasurer for St. Croix County, Wisconsin, and find no record of un-
paid taxes or assessments standing as a lien on the real estate described in this abstract, except as shown
herein. Such examination covers up to and including the taxes for the year 19 83 .
That this certificate and annexed abstract and also any prior certificates, if any, made by the un-
dersigned, covering the some land, are furnished for the use and benefit of any and all owners of the land
described in said caption and their successors in title, including mortgogees and guarantors of title.
Dated at Hudson, Wisconsin, this 2nd day of August A.D.
19 84 at 10:45 o'clock in the A. M.
ST. CROIX COUNTY ABSTRACT COMPANY
By
ASS T cretory
T\TLL ~\1\
SEAL
TITLE SEARCHES ESCROWS TITLE INSURANCE CLOSINGS ABSTRACTS
RIVER VALLEY ABSTRACT & TITLE, INC.
220 LOCUST STREET
ROGER D. REVERS HUDSON, WISCONSIN 54016
PHONE (715)386-7772
EL TTER OF TITLE
Description:
Part of W 1/2 of NW 1/4 of Section 17-29-19 described as follows:
Commence at W 1/4 corner of said Section 17; thence N2030'W 102.4
feet; thence N74°29'E 306.9 feet; thence N54°24'E 211.8 feet
along a roadway; thence N63°16'E 254.8 feet along roadway; thence
N3°04'E 363.6 feet along roadway to S line of parcel conveyed to
K. B. Priester and Ethel Priester, his wife; thence N75°14'E 256.2
feet on said line to SE corner thereof and Place of Beginning;
thence N26°37'W 441.6 feet on E line of Priester land to Willow
River; thence N19°07'E on meander line 86.0 feet; thence S68°33'E
287.0 feet; thence S10041E 294.8 feet; thence S53°26'W 128.3 feet
to Place of Beginning.
Together With all land between meander line and Willow River and
Together With easement over access road as now opened and traveled
from Town Road.
Grantee of last deed conveying above described property:
Terry G. Domino and Barbara J. Domino,
husband and wife as joint tenants.
Mortgages:
Mortage to First Financial Savings and Loan Association in the
principal amount of $160,000.00 dated May 31, 1984, recorded June
4, 1984 in Vol. 689, page 412, Doc. No. 393809.
Taxes:
Taxes are paid through the year 1988.
Judgments and Liens:
NONE.
Dated at Hudson, Wisconsin, this 27th day of November, 1989
at 8:00 o'clock in the A.M.
RIVER VALLEY ABSTRACT & TITLE, INC.
BY:
Roger D. Bevers
r ' CA
• H
a
ST C- 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
9
_ H
OWNER/BUYER E?rr+V ursl 4r~ U`!Yt i ~Q
ROUTE/BOX NUMBER q7y 1_uvv-- -Fire Number a7~-
CITY/STATE H ~ an ZIP 54016
PROPERTY LOCATION: _'C' z~J 14, 1A)' Section /'7 , T Z15 N, R__I_I_W,
Town of . St. Croix County,
pp C
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.
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.
0
E
I/WE, the undersigned, have read the above.requirements and agree En
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- 10
ment 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 Z I 'j -
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
-LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53969
'HUMAN• ,-9fIONS
OLHR 83.090) & Chapter 145)
LOCATION: SECTION : TOWNSHIP/ OT NO.:BLK. NO.: SUBDIVISION NAM :
VI'/ N 1-7 /T 7-9 N/R it9 E to pst,w -
COUNTY: MAILI ADDR .
C26TEaR 11~ f 4k4 QOM) T74 PR, s 1 otl%w/
USE DATES OBSERVATIONS MADE
NO. B DR : COMMERCIAL DESCRIPTION:
3: PERCOLATION S.
Residence ❑New n Replace 4
'OILS 200VL PJdU ~ Sans Na_ Ii"LtA►Iy,F Ica
RATING: S- Site suitable for system U- Site unsuitable for system
0 EN I NAL: IMOLIND: IN-GN S -IL OLDING TANK:1RECOMMENDED ^O,yV6rJT ~NAt EM ()plPba~tKl~ES
S DU 114S ~U S~U aU ~S
If Percolation Tests are NOT re uired DESIGN RATE:
Q If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: CLdss 1. 7 1 Floodplain, indicate Floodplain elevation: AIA
Ndc~zr PROFILE DESCRIPTIONS
BORING TOTAL P H T R UNDWATER-INCHES CHARACTER O SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH-=. ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- I 6 ,~S 97.74 0 > 6,7S o ~Sf_~S S"Ra P,.Ms Z6~Ro6e+~ n,5 ~~~e 'cob
B-
B- 2 9.G_7 O C 7 8.6-7 r~LSLI S IZ rt1QA 8L~ /6 "Rfl~~G~ ~ BRA gQ^~ ~S`~ ~i+~
B' 64'"8 eN G~
B- 9A-Z 9g. 1 > 9, AZ ,"Bwrs 13" RABa,,, Fs csi&k
B- 38%-r$a Csf4rt 40" (~o$a Cs~G~ cob
PERCOLATION TESTS
c.Ft-
} DEPTH WATER IN HOLE TEST TIME -DROP I WATER LEVEL-INCHES RATE MINUTES
r NUMBER S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PER INCH
P. 3.Ao NONK g1-60 j Z ! Z / _ 7
P- Z 3.150 Nomg 97.90 3 >2 >2
P_ 01-IY .4c) 1Z <
P-
P- ,,LVIkr1 AT pr-
P-
/nIQ IPL ON LUCFt.INE AT &N,& 07- EhK#LQNL/
PLOT PLAN: Show locations of percoldi n tests, soi borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference qoi is and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
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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►:
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CST SIGNATURE:
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DISTRIBUTION: Original and one copy to Local Authority. Property Owner and 'ail Tester.
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Route 1 Box 192 SHEET NO. OF
WILSON, WISCONSIN 54027 CALCULATED BY DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc, Groton, Mass. 01471. To Order PHONE TOLL FREE 1-8*225-6180
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TIMM EXCAVATING SHEET NO. OF
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY DATE
(715) 772-3214 (715) 386-5443 DATE
MPRS #3224 WI MPCA #696 MN CHECKED BY
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PRODUCT 20.5-1 eea Inc., Groton, Mass. 01471, To Order PHONE TOLL FREE 1-800-225.6380