Loading...
HomeMy WebLinkAbout020-1151-50-000 o 0 d 00 0. h N N ~ C ill N .0+ z c it LL o 3 0 a v 03 Z E O z N w a m F- G O O Z w p d z :t 2 N N F- r E -2 O N M N 0. y (D • uyi a) o L L - CL C c O U N a 0 z H z p N Z d C (V w , R E ~ ~l N a GI O c O y D d E~ N w d c0 fA l/) FrN,. c N O WJ a ° s _ Z ° aaa CL t~ J U v m 0) ~ ! = o rn a y O oo ° ~ m a ? m m y c ~ N a> m I~ d aY in 6 ~ 7 0 n N c p C Z' C E CV Cl) In O O M 3 N U 0- °0 m 0 co CL r_ E 10 o CD y C CO N +0" 'O r O O ICI O CV j m O N .6 • O O N 2 fn r O Z C' Cn V C~ , EL L (L • e~ .2 U1 A 00 IL 2 ~ 0 U) to) V . Form - S T C - 104 ' AS BUILT SANITARY SYSTEM REPORT • • OWNER' ' Sc^vc' TOWNSHIP SEC. '247 T .2~LN-RW s_;~$~^•, I(L~c_: n LA ADDRESS z S k ~j ST. CROIR COUNTY0 WISCONSIN , P . . • ~ i v c ~ -e ~ 1 h E' S SD ~ 6~ ~G•i v~ ~coucv CS~•A'2~ ~O~ 2 f SUBDIVISION T SIZE L~IL~ . -1 2.-.5 67ri P-hna 0-Y-, PLAN VIEW \OF Distances and d imensions to meet requirements ? 1cj Z~j SHOW EVERYTHING WITHIN 100 EM - . ~s:.. .r :1.11:. ~ ~ • , . • rte... i 1::1 • I .1 ~ la".~ 9':! ~ ~ 11 . ♦ { . 1 . ► ~ V Gar .i11• 1. t INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used f Elevation of vertical reference point: Op Proposed slope at site: SEPTIC TANK: Manufacturer:' l~•E'-' S Liquid Capacity: 60 i•'••{•Numbe= of rings used: Tank manhole cover elevation: Tank Inlet Elevation! Tank Outlet Elevation: ~lP 1 ' Number of feet from nearest Road: Front 10 Side0 Rear, ~f f feet • From nearest-property line • Front.0Side Rear,O feet Number of feet from: well " building: (Include this information of ..the above plot plan)( 2 reference dimensions to septic tank) SEE. REVERSE SIDE J PUMP CHAMER C Jv 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 feat fiom.nearest property line:'. Front, O Side, O Rear, O Ft. 'Number of feet from well: Number of feet from building: (Include distances.on plot plan). SOIL ABSORPTION~SYSTEM: Bdd:-• Trench: 1_ 6 3, . Width: t Lenith: I•- leY r -.Number of Lines: ~k_ Area Built: Fill depth to top of pipe: Number of feet f''m nearest property line: Front, O Side, O Rear, e-Iii,.~ fNu:nber of feet from well: / . N 'ber of feet from buildings _ (Include di lances on plot plan). SEEPAGE PIT Size: Number of pits: Diameters ' Liquid depths Bottom of seepage pit elevation: Area Built: Has either a drop box O or diat-ibution box O been used on any of the above soil absorbtion sytems? (Cieck one). HOLDING TANK Manufacturer: Capacity: Number of'.rings used:. Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property lines Front, O Side, O Rear, 0Ft.__. Number of feet from well: Number of feet from building: Number of feet from.nearest road: Alarm Manufacturer: t f b. I i fis Inspector:.-* Dated: - / - y Plumbar,on jobs ~e License Number: • F 1.4 3/84:m' j t SAFETY & BUILDING ENT OF INDUSTRY, INSPECTION REPORT FOR DIVISION LABOR dr HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVW,4ON CODES & APPLICATION P.O. BOX 7969 State Plan I.D. Number: (If assigned) SIDIwlec.29,T29-R19 CONVENTIONAL ❑ ALTERATIVE Town of Hudson El Mound Glenna Drive Lot Holding Tank ❑ In-Ground Pressure INSPECT I0 D TE: NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: 55104 Gary Swanson 3926 88th Ave. N.E. Circle Pines, REF. PT; ELEV.: CST REF. PT. ELEV.: BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: yjrj y j C Sanitary Permit Number Name of Plumber: MP/MPRSW No.: Cc fnty: 135480 Bennie Helgeson 3215 St. Croix SEPTIC TANK MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV./ / TANK OUTLET 7ELEV.: PROVIDEDLABEL LOCKING COVE r. v / ! 9 pl 9w• 7/ YES ❑ NO ❑ YES NO / PROPERT WELL: DING: VENT 0 ESH BEDDING: DIA.. yE1l~MATL.: HIGH WATER NUMBER OF ROAD: LINEy t AIR INLETn : ALARM: FEET FROM '41 C O, / ❑ YES NO ❑ YES NO NEAREST DOSING CHAMBER: WARNING LABEL LOCKINGCOVER MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑NO ❑ YES ❑ NO PROPERTY WELL: BUILDING: VENT TO FRESH PUMP AND CONTROLS OPERATIONAL: NUMBER OF LINE: AIR INLET: GALLONS PER CYCLE: FEET FROM (DIFFERENCE BETWEEN ❑ YES ❑ NO NEAREST PUMP ON AND OFF LENGTH: DIAMETER: MATERIAL AND MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: INSIDE: CIO # Plrs: LIQUIp a " WIDTH: LENGTH NO.OF Dill STR.PIPE SPACING: COVER ERIAL: BED/TRENCH f / TRENC~IES: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH DIMENSIONS of 1r_ - GRAVEL DEPTH FILL DEPTH DIS R. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: FIPF,S~. NO.FSI TR. LINE: AIR INLET BELOW PIFFS: ABOVE C E t: EL T: E ND: yn5cior`y~G FEET FROM I Y CST NEAREST CL/ MOUND SYSTEM: , Mound site plowed per n i ul D 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. _ _ PERMANENT MARKERS: OBSERVATION WELLS; SOiL COVER TEXTURE: ❑ YES ❑ NO ❑ YES ❑ NO SEEDED: MULCHED: DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER: BED/TRENCH WIDTH: LENGTH: NRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE'. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NNOE DISTR. DDIS ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKIN : ELEV.: ELEV.: DIA.: ELEV.: ELEVATION AND DISTRIBUTION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: APPROVED PLANS INFORMATION ❑ YES ❑ NO El YES ❑ NO PROPERTY WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LINE: COMMENT FEET FROM r ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ( / ✓ ~ Y~ 11C 1 ! W~ ilc.. r ~Q ~~j1~" ~•-iii y- may- /K ~ :-K. (sue hl ;f ~ thin in county file for audit. Sketch System on SIGN URE: TITLE: Reverse Side. tilt) k. SBD-6710 (R. 06/88) cx- n SANITARY PERMIT APPLICATION :M&HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 3 8% X 11 inches in size. Check if revis to r iooapplication -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 Gary Swanson SE 1/4 SW S 29 T 29 , N, R 19 V4or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 3926 88th Ave. N. E., 14 N/A CITY, STATE ZIP CODE ~PH E N UMBER SUBDIVISION NAME OR CSM NUMBER Circle Pines, MN 55014 2 786-2242 Presidential Aves. NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE : Hudson Glenna Drive IOWN 09: TAX N MB R - _ ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PARCEL 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑Outdoor Recreational Facility 11 ❑ Restaurant/Bar/Dining 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 4 ❑ Church/School 8 El Mobile Home Park 12❑Service Station/Car Wash 13 ❑ Other: Specify 5 ❑ Hotel/Motel 9 ❑ Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. EX New 2.E1 Replacement 3.0 Rank cement of 4. ❑ EReconnection of x sting System 5.E] Ex sting System System System Y Date Issued B) ❑ A Sanitary Permit was previously issued. Permit # - V. TYPE OF SYSTEM: (Check only one) Other Non-Pressurized Distribution Pressurized Distribution Experimental 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank ❑ 42 ❑ Pit Privy 12 ® Seepage Trench 22 ❑ In-Ground 43 ❑ Vault Privy 13 ❑ Seepage Pit Pressure 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. ERC. RAE 6. SYSTEM ELEV. 7. EFINAL LEVATION GRADE k0c REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) 660 660 .68 1/3 93.86 Feet 97.86 Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in altoI Total # of Manufacturer's Name oncret Con- Steel glass Plastic App INFORMATION New istin Gallons Tanks structed Tanks Tanks Septic Tank or Holdin Tank 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. MP/MPRSW No.: Business Phone Number: Plumber's Name (Print): LPlumber's Signature: (No S ps) 715 778-4425 B nni Plumber's Address ( treet, City, State, Zip Code): Rt. 2 Spring Valle WI 54767 IX. COUNTY/DEPARTMENT USE ONLY Sanitary Permit Fee (Includes Groundwater ate Issued Iss in Agent Signature (No Stamps) ❑ Disapproved Surcharge Pee) Approved ❑ Owner Given Initial / C.LC- (((~~Y Adverse Determination ( L JJ w4Q 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 r ~ 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. "rhe 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 systern. 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) r APPLICATION FOR SANITARY PERMIT 8TC-100 This application form is to be completed in full and signs tby thelo elayi of the property being developed. Any inadequacies will only the permit issuance. -Should this development be intended tot resale by ovnst/contrector,(spee house)- then a second form should be retained and completed when the property Is sold and submitted to this office with the appropriate deed recorprog - w w- -w- --w------- w-- - --w-----------w---- w • - -w-- - - Ownet of property S ~So i/4, Section T.----~'•a.Y Location of proper y~7 1/~ = Township V Mailing address ~a2 c il~ C Address of site subdivision name ~l c SSG Lot number previous owner of property Total also of Parcel onre Date parcel was created At* all corners and lot lines identifiable? Yes -__-_.~o Is this property being developed tot resale tapes house)? as 0 Ve190e ---.and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION TITS FOLLOWINCt A WARRANTY DASD which Includes a DOCUMSHT NUMBER, VOLUMti AND pACt NUMB and the S9AL OT THR RE028TSR Or DEED9. In addition, a certified survey, It available, would be helpful so as to avoid delays of the reviewing process. the deed description references to a Cestlfled Survey Hap, the Cettifled Survey Map shall also be required. f_ PROPERTY OWNER CERTIFICATION I(vel certify that all statements on this form are true to the best of my (our) ttnovledgel that I (ve) am (are) the ovner(s) of the property described In this Information form, by virtue of a warrant d ed ec d In the Oftfsf the County Register of Deeds as Document No. 1 and Presently own the proposed site for the savage disposal sYs*~ obtained an easement, to tun with the above des'-" conatc ion of s d system, and the same has et t vunty Re stet of Deeds, as Document Ht s gnatut of owner sign& 0 Date of Signature Date t~ Y THIS SPACE RESERVED FOR RECORDING DATA DOCUMENT NO. ~I WARRANTY DEED I STATE BAR OF WISCONSIN FORM 2 -1982 .I JOHN W. VEGTER and CANDACE F. VEGTER . j husband...and.•wife_,...Grantors ~I coneys and warrants to ...GARY..W,.., SWAN$QN..-aid.. CHEI~YL•-D,,-•. ` Ij .......SWAN SON.,... hushand..,a.n d-.wi f.e.,...as...survivn rshig..... j marital...Prnperiy..,...Grantees f II j - RETURN TO I . St Croix ....................County, the following described real estate in ~ State of Wisconsin: Tax Parcel No: Lot 14 Presidential Estates, Town of Hudson, St. Croix County, Wisconsin. TOGETHER WITH AND SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if any. homestead property. li This 1S not 00 (is not) Exception to warranties: i 40. 30th April 119... Dated this day of (SEAL) ja (SEAL) TJ I- --VEGTER .......(SEAL) . ..............(SEAL) * • . CANDACE...F.:.. VE.. ..R.........--••----...... AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. i authenticated this ........day of 19...... Personally came before me thus,.. April...... ,p John.W,._ TITLE: MEMBER STATE BAR OF WISCONSIN Ve e-._. (If not, ...~to authorized by § 706.06, Wis. Stats.) to e k be f ego' ng instrume/; THIS INSTRUMENT WAS DRAFTED BY Lnen Attorney..Barr............................................ 110 Second St. , Hudson, WI 54016 Notary Public $ - (Signatures may be authenticated or acknowledged. Both My Commission is pd are not necessary.) date: I I *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY nERn STATE BAR OF WISCONSIN D OCLI,~^n ~P THIS SPACE RESERVED FOR RECORDING DA-7A WARRANTY STATE EAR of VTIS+-~ONSIN F011M 2 - 1982 JOHN W. VEGTER and CANDACE F. VEGTER, for Reel husband .and wife,_ Irantors__ 141, is 1130 A. - - ' - - - - - - - - - - - rnka. co rn urar, i GAMY W. SwANSOI - and .CHERY.L D. - °t~gistor of ITT-, -.husband---an_d__za_if as . sz urvrvo_rsh•~ p------ --aYi* al Fr_cgLY~.v., - - - - - - - PE7uRN TO t- 01.'. v n- deSC ? a E'.5.ats fi 1 r . . ; a^C< t _ - vro~ --rm,rt~•~ _ - - S`.-_?te c1 W'sco_ns:n: Tax parcel -NO: C o!x CoLiaty, ~Jt r eSiCC 1t _al -states, . own of rT77dscn, St. n isconSin. T-^ W Tm-~- - r m m/~ T 0 G E -i_R n~_s _ ANA 0JB EC T'0 reservatior_s -restrictions, easements and. r_g=zts-oi x7ay of record, if any, rte' mla o rnnleci-na~' p..G~P^}.. (is not) 2-xcC^t'on to -,yarantles: n.s - - ^ n day o Ap , - - - - - - - - - - , 19- J - i - (SEAL) - EA - T t NN TT T ; ± Lit - - - - c A - - . SEAT CAN~t~ ,~'r•" C VEG~ R A73Tl7, EN TIPCATI®N A C E N 0 v_T_EI?CTMENT Si •rature(s) - - STATE OF 77iSCONSIN r ~ ss S Croix County. authenticated this clay of , 19 Personalty Came before me this 30th G ApriX------------------------------ 19-- 'Q tL John W-------- VeP~ 'r L E : M, E-L?BER STATJ BA 1? OF rh'ISCCNSI\ Ve xteT fir ??O_ - 1_____ authorized by -s. Stats.) tp kp/o rn to be instrume. TH!S !NST'~uN.E4T WAS DRF=TED DY i At------ tcrey Darr", C. rCeer l0 Second St., ~r dson, l 54 75 - _ Ny _ 1dLc/ x t Con!- . i (Signatures r ray is ay be authenticated or ac~cnov*,I~_PC- • are no eees x F.. n 9v y) J r Gate C "Dames e_* persons s'nring i,, tiny capacity shoaid be type'! or psintod bo:ov, their siq atures. .._,ANTTl T 71-_ STA' E nAR l,, Or G1. ^C*"'ZV W SEPTIC TANK MAINTENANCE AGREEMENT rt r St. Croix County ~ n OWNER/BUYER w 0 S~0d (,Fire Number ROUTE/BOX NUMBER 0 CITY/ STATE ) h ~f J f _ZIP__ rt PROPERTY LOCATION _34's-(' Section, TN, R/L? W, Town of St. Croix County, Subdivision ~Er ot number Improper use and maintenance of vour 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 .se tic tank um er. What you put into the system can affect t e .unction o t e•septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents may be eligible to recieve a grant for a maximum of 60% of the cost-of replacement of a failing system, whit 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 system properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a mater 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. y 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, asset by the Wisconsin Depart- ment of Natural Reog~ceCroixeCountyaZoni fo0fficstwithinm30edays and returned to the of the three year expiration date. SIGNED DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. i DEPAhTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS "INDUSTRY, DIVISION LABOR A PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.090) & Chapter 145) LOCATION : I N: 4 TOWNSHIP/ ~+TY: OT NO.:BLK NO.: J ISION NAME: s~ 4sw~ 29 /T2y N/Ri3E(a HuDSe...) I¢ - PRESIDe.UTAL ACgS COUNTY: MAILING ADDRESS: Sf'•CR0fx GARY jCkerRyL SWAJSoI Jf2G g,P tl~l 11U-Q • Ji`l CIRcI& T3iAJt S Af,j SSo USE u`/E )?S 02 ,W 13-- - Z L t- e G ~7' S O DATES OBSERVATIONS MADE NO.BEDRMS. COMMERCIAL DES RIPTION: Residence / /V , ,Q._ ❑New ❑Replace [API'-';L 2 ~ ?Z) 1APPil 3, - f O U R k RATING: S- Site suitable for system U- Site unsuitable for system SC5 O (Da ONVENTI NAL: MOUND: IN--GROUND•PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEMAciptional) -tS ®S ❑u L7S ❑U ®S []U ❑S ©U ❑S DU -dNuEAiTfDakl.- - 7-I t 4 If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.0915)(b), indicate: t^L r4 S S = Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R"UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. I HE`'T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) v ' T~ c s 13- g, C9 le 6, • eo u eke s , 7 B. Z ~S 94 ! 0 O . S 5. S ' 4,4--n s V , B-3 P, .0,5 S 'ge/,.,,.isJi .S' s)P -7,5 rew CS 0' ~f7.yL~ > /,o' Ba SI,r T/}„ol ut-roy ms's BS B~.S \ 97.~G >'S B.y• s . G s Z3N -sue- s c B- ,$-'F-j~~^y(,}S PERCOLATION TESTS tN ue-Ry C-5 TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER L V H RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. =Fi-gjQp-1 ~BQD PER INCH P- r - Yr p- L S. Z - - - 3 P. 3 Z-- - - G Y EPP-::. PLOt PLAN: Show locations of percolation tests, soil borings arid 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. ~4 L^ ~s I I ' See- 'Re P oT p r I i i U S E- S i A7 r 'This test "Tt', r..._ ' aMa Ir..q 1 `1•/ (.6i\ UN~O74' ..+ar • _ _ ~ 7_.. i 1 I -4- i I I L-t OU)A 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: HOMESITE SEPTIC PLUMBING CO. A P P; (4 Q ~S ME14~E10.~ HUDSON, WIS. 54016 1 ADDRESS: ROBERT ULBRIGHT CERTIFICATION NUMBER: PHONE NUMBER (optional): WIS. MASTER PLUMBER LIC• NO. 3307 M.P-R,S. 2 17 P 2- 3 1Q7 G - IF/ 11~1 S '"INN.INSTALLER DESIGNER U+-N 00663 " CST SIGNATURE: k, 6 C4,4; DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Sort Tester. J J;R $ :E 2D ,cry ~ ~ ~ ~ -r nl c 2 G h r ~ N A S s v•,, L V wL$ 1' LOT L h Z O $~I p P,lAl_ I I ~ c ~ • Spy I_UI~ I n' 1 r• ~G I b ~ ? 1 vi `s~o(zA /0 ~6 l y l I I J7 - ~ ~ IrI ~~161• -1 I I - rr ,.u 7 v ICI 1 I ~ c0 1 1 I i .u C;i IC Cl) XX TD (TI 1 I ~ IL~I ~~sr ::j • mr•1 ~ I L~Sr • ' p W ~U n C~ c "r7 h C '0 - p ~ D L R N. L y E LA p 1% a o~~ o o K E d 1 lb) A ~ •q P 10 ~i N CR -Ai \i ` TA a® ~ P G 41, rt; E ~ ~s Cp p N - z ~ ~ Pv ~(CT o fro s5 5 ~i~t~ m ~ 5°- s go -37o p r ~ ~ ha ~ ~rro..d e~ ~H~~h as rock ~,s~}►-~be._tcm,~ over P~~,e Sml~' td~ P, P r- Flees. ur_ rj NQV ~rj7~ ~ w ~ roM Je~ ~rC . y } . DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUST~,.Y; C DIVISION LAOCIR AN P.O. BOX 796 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON W1 3707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/M4N+9W*b+TY: OT NO.:BLK. NO.: SUBDIVISION NAME: se ysw1/ 29 /Tzy N/R17E(o >HuDSe .j 11- - PRES►DE..)T^L. !9~•Cs COUNTY: MAILING ADDRESS: 5-F.CR6tX 6APY 3,C~tRVL SwANSo j 3926 S,P f~- AU-e _ 1J'~ CIRc1F' PiAjt S AfA-) SSo USE B u 11 - S & 12 - -78 - 2_27Z 41je G 27- S O DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: 79MEE DESCRIPTIONS: PERCOLATION TESTS: PResidence ❑New ❑Replace I APP. L 3 if e A PP; I" 3 y 0 I RATING: S= Site suitable for system U= Site unsuitable for system 6C_ 5 ~RV Q e A A R D T O(NNVVENTIONAL: MOUND: IN-GROUND-PRESSURETO YSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:loptional) I~JS ❑U DS ❑U R1S ❑U S ©U ❑S DU "UEAITrO-4J A- L_ - Tf2t Ai C4-4 S If Percolation Tests are NOT required DESIGN RATE: = If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: CLy4.S S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO 'R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH I EST. NUMBER DEPTH IN, ELEVATION OBSERVED I H T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / D 98.8 ~v > d', d l,a ' IS -j . `0 u le44 s , 7 o ' r,*, C s ,rte,,, s, s' a 2.o' A.) v CS ' B- 3 f S 9P• ~Z t Ite S ' s ot- ZAJ . s ~ 7 S • ~ ,J p A, t C$ B- > v' ~,o BN s~ 7, T4", v~'r4y ~s BS • S 77, ~G - S CA s w I' ad-d- . B- PERCOLATION TESTS 'N UE-Ay CS S*-A^-y4S EST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P RI `D t P RI D 2 PERIOD3 PER INCH Y,r P- 1/0, P_ 2- .3, 17 ' Z - 3 P- 3 / - 4 G 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 ;how their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. qP& r SYSTEM ELEVATION. 3_ I ~e f'~ r~4 ~s P L ur p ~1t -i See 1 i I 12~~>r RSE S _ I r - I I I _ i , 1, 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: HOMESITE SEPTIC PLUMBING CO. P 2i L - I `t q O 655 O'NEIL RD HUDSON, WIS. 5016 ADDRESS: - ROBERT ULBRIGHT CERTIFICATION NUMBER: PHONE NUMBER (optional): WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. 2 V 4, Z 3 f -,?/4> S 'INN. INSTALLER A DESIGNER LIG.1M. OM CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBO.6395 (R. 10/83) - OVER - I ~ ~ ~ m rN o _ AS its q, o to Assv~ t V ZO N i 1 I \1 1 1~ 1 ~ 1 ~p96 ICI 1 Ifs J7 1......_.` I hl R ~ i I~1 ~„I A c 1~1 1~1 i i~l 1 1 y 1 I~I 1 1 ~ I 1 I 1 x I I I Ivl~ C o I I 1 1 ~ I 1 I I fi rl I I I 1 ~1 ~ 1 I 1' ` 1 I I 1 'f~l N . _I 1 1 al 0 w v ' n C 1 ~ 7 -6 Z -o o c -o O x > L v► ° it a PD. o ~c d F, (Ti J