HomeMy WebLinkAbout161-1050-90-000
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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER He- I~, nI L ~ N I ~ TOWNSHIP V t ~ ~f~ GST NU (7SQ /1/
SECTION T~N-R_~)Q W
ADDRESS kf eM St . ST. CROIX COUNTY, WISCONSIN
Nor_tk "(Ao,)w
SUBDIVISION MA LOT_&IA_LOT SIZE A)A
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
.I
Foece MIA)
3 Beurtoom
i , Se ;c Pu~P
Char~beK.
y
GARAJe
x
Bw
CAS' Prop W(
R, AV')
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: Ioh O~ 7oUNoAfio#l CoKweK
Hou3e elev. = 100.0
Alternate benchmark 11
f.
SEPTIC TANK:Manufacturer: wt-e_ K S Liquid Cap. 1000
Rings used:3-Manhole cover elev: 9 7.50Final grade elev: U
Tank inlet elev.: 3. a_D Tank outlet elev.: 9o
No. of feet from nearest road:Front , Side X , Rear Ft. Ve )56'
From nearest prop. line:Front , Side) , Rear Ft.
No. of feet from: Well WA f , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
•
PUMP CHAMBER ~1
Manufacturer: W ~S -Liquid capacity: dV
Pump Model: Pump/Siphon Manufact.: Oe~I¢R Pump Size 'a HP
Elevation of inlet:il~&a Bottom of tank elevation 8S. I C7
Pump on elev.:91.13 Pump off elev.: 0•olGallons/cycle: 30 LHON S
Alarm: Man.: Switch Type: Location ZN 045P_
Distance from nearest prop. line: Front_, Side(, Rear_Ft._
Distance from: Well- C'jhj Building a f
sha-t4~ov Heanerz
SOIL ABSORPTION SYSTEM % ~ ~ toy
1 u.~ mss:. `LN0
(0 -Los
Bed: Trench: Seepage Pit:
Width: Length _ Number of Lines:__a_Area Built a
Exist. Grade Elev. 18.10 Proposed Final Grade Elev.
Fill depth to top of pipe: Do " y all
i
No. feet from nearest prop. line:Front , side X, Rear Ft.
No. feet from well: i yr_No. feet from building
WA1eR
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side Rear Ft.
No. feet from: Well building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: )so PLUMBER ON JOB: - its 1~OV.,l~1PP 4~Q lE'
LICENSE NUMBER: 3 Oaf
6/90:cj
15EPA ATMENT 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:
NW 4 , NE 4 , Sec . 13 , T29-R20 CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of N, Hudson t 1~
I-I Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
14plpn T.aniq ~ 207 Helen St., N. Hudson, W1 - D c) '
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. E r
ry ;0,C7
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
128848
l~' EPTIC TANK/ J C'Ve" = Gr
3C/MANUFACTURER: LIQUID CAPACITY: TANK INLET TANK OUTL WARNING LABEL LOCKING COVER
P O IDED: PROVIDED: d.C
"6w i,~R _P ~ , 1 YES ❑ NO ❑ YES N6
e BEDDING: DIA.: MENf-MATL.: HIGH WATER NUMBER OF ROAD: PROPE WELL/ 3 BUILDING: VENT TO FRESH
c•v, ALARM: FEET FROM LINE: r AIR IN T
V] V ❑ YES NO YES NO NEAREST 'YO
DOSING CHAMBE . 9, _-.,V,,17 Ll / ?e../-98• G Sri ' - l~ o R(
PAtTr PUMP MODEL: PUMP/SI - UFAC URER: WARNING LABEL LO R
r.- ~
MANUFACTURER: BED LIQUID CA
PROVIDED: PROVIDED:
❑ YES NO F/0 Lv[ (-)2 1 G 41 ~ WYES ❑ NO YES ❑ NO
GALLONS PER CYCLE: UMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUIL NG: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: r AIR INLET:
PUMP ON AND OFF YES ❑ NO NEAREST---* jo e
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATE IAL AND MARKING: AST-/►2-~ -
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN 35 / 02P~/G
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: v GLel/, = v 71W ,
WIDTH: LENG N OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH
/ TRENCHES: MATERIAL: DEPTH*
DIMENSIONS 111 / ~ G ar
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTe. PIPE ~v1AJ RIAL: N ISTR. NUMBER OF PROP 9T WELL: 3 BUILDING: VENT TO FRESH
Q/C yCX_ PI ES: LINE: t. AIR INLET
BELOW PIPES: ABOVE COVER: ELEV. INLE ELEV. END: NU
j y.. FEET FROM / J
CO NEAREST v2
MOUND SYSTEM: 8' S,7s' ww
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: OBSERVATIO LLS;
❑ YES ❑ NO YES ❑ NO
DEPTH OVER TRENCH/ BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES E__1 NO ❑ Y S ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM: ~C70 of 6Cock e,," &,A-
BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL FTR 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
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
A5 g r ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ----00-
~Ci.!..~".7•'-,1t:IC<[F' j L2r.r i? ~TGi1,C.(~ ~L~-~_` (
~ ~ Q ilt'" ~ ,c.C~-i.de ~ ,!v✓~ C~,-. ter. / ~c, w~--~' . , / off' ~ ~ Z` ~
,-nos. - -
3 ~ ,4L U., Uew_ ~ yob' ' J
Sketch System on Re in in unty file for audit.
Reverse Side. ;RE-
SBD-6710 (R. 06/88) y
'DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 8%x 11 inches in size. C eckif Zoviorto evious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNT4.
_1
PROPERTY LOCATION
411 V05
t 'iR Y4 Y41 S T ~ , N, R ~ E (or)
PROPERTY OWNER'S MAILING ADDR LOT # BLOCK
Q0 e S,
CITY, ATE ZIP CODE PHONE MBER SUBDIVISION NAM R M NUMBER
-171 ITY
II. TYPE OF BUILDING: (Check One) ❑ State Owned VILLAGE \U NEAREST T
Li d4osol
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX N MBERO ~
e S~
III. BUILDING USE: (If building type is public, check all that apply) 09 IV
1 ❑ ApVCondo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining
40 Church/School 8 ❑ Mobile Home Park 1120 Service Station/Car Wash
50 Hotel/Motel 90 Office/Factory 130 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 TZ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQ IRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) _ ELEVATION
~-1 7 1 Lo .7a r `15-75 Feet 98,7S Feet
VII. TANK CAPACITY Prefab. Site
in allons Total # of Manufacturer's Name Con- Steel Fiber- Plastic Exper.
INFORMATION New Plating Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tank or Holding Tank )V N 1 u
Lift Pump Tank/Si hon Chamber @00 (,1 2 S
Vlll. 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:
~rv\ Ba ~ >r~~ -e It 38(0 ?Q
Plumber's Address (Street, City,,State, Zi Code):
90) V-61 s 4 n-66N V, s,- 's V
IX. C LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ant Signature (No Sta
Surcharge Fee)
Approved ❑ Owner Given Initial /
Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
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 priof td installation.
5. Onsite sewage systems must Tie 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% 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 ~(,j Ee c' d c,.) 9 R~ s
Location of property 6~ 1/9 /4, Section 1-3 , T_,23 N-P'112 V i lla~~
Tewft&~'fr'
p (V a(46\ 0 LA s ova
Mailing address o~C7 I~7~~/~Y1 Sf. /P.
fNr-~,dsao / SYo/(c;,
Address of site c 07 ~f /F v~ S~. /yuno 61)/ S YD/(v
Subdivision nameg5/~ (-_dd~
Lot number /o~
Previous owner of property E f vS Llu 49
r
Total size of parcel l~/6 X cc,
Date parcel was created
Are all corners and lot lines identifiable? No
Is this property being developed for resale (spec house)? Yes No
Volume and Page Number kt'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 references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. _3 ID R ; 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 dul recorded in the Office
of the County Register of D ds, as Document No. 31G?
Signature of Owner Signature of Co-Owner (If Applicable)
LI? ' C D
Date of Signature Date of Signature
DOCUMENT NO. STA'I'F': I3AR OF R'ISCO'IS*", - FOF:M 2
tl ~j J I WARRANTY DEED
~J THIS slrncf atstRvct) foP PECO1ti~iNC; DATA
BY THIS DEED, Gene F. Hustad and Ardys J. ~
_Hustad, his wif-e, _
- f f JttCle 7~>
'rancor conveys and warrants to _Edw_&rd_A,__l.anis-_and_Helen- M._-_ _
Lanis,_- husband__ad as _1o~nt _ tenants ut i7 }0
for ~valuable consideration ...Forty Thousand. Dollars
I RETURN TO
the following described real estates in Ht Croix County, StateofWiscon ,in;
Part of theEast 100 feet of Outlot 68 of the I.xhy,
sciribed tasa•Sti;i~l''r,~t>,rt~.
Assessor's Plat of the Village of North Hudson deI'l
follows: Beginning at a point on the east line of said Outlot
68 a distance of 140 feet south of the northwest corner of
Lot 12 of Kask's Addition to the Village of North Hudson,
thence north along the east line of said Outlot 68 a distance
of 140 feet, thence west 100 feet, thence south 140 feet, thence
east 100 feet to the point of beginning; together with an easement.
for an access road over and across the south 20 feet of the north
50 feet of Lot 11 of Kask's Addition.
¢o-od
Exception to warrant nt s;
L,x~< rated at Hudson, Wisconsin /
till!; I.ry "f June l0 72 .
SIGNED AND SEALED IN PIiISSE:NC f': OF _ ~l4'1 -7
(SEA1,)
Gene F. Hustad
C cY
SI:AI
Ardis J" Hustad
(SEAL)
Siirnatures of Gene F. Hustad and Ardys J. Hustad, his wife,
authenticated this - - - - day of - June 1,)72 .
Thomas G. Grover
Title; Metnher Stato Liar of Wisconsin ar'{ rerPmr9-
Authorized under Sec. 706.06 ~,XX
STATE OF WISCONSIN
County.
Personally came before me, this `
day if I()
the above named ,
to me known to be the person _ who executed the foreVoing instrument and acknowledi,,ed the same.
This instrument was drafted by
Hugh F. Gwin, Atty. _
Hudson,-Wisconsin. _ Notary Public.
County, Wis.
The use of witnesses is optional.
My Commission (F?xpires) (Is)_._
Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED-STATE I3AR OF WISCONSIN, FORM NO tic M.ue, c<ny,.+v~
aqor 19485 F~ ~E 491
Mato of HV'ncondo
County of St. Croix
qi
I hereby certify that this instrutant►t IS
true and correct COPY of the document Can fta
and of record in my office and has been
compared by me.
arrest NovemhPr 8 19_2Q_
James O'Connell
,aa». a GXK 0006
Deputy
SEPTIC TANK MAINTENANCE AGREEIIENT
St. Croix County
OWNER/BUYERn ~o, A R~ /9 i S w
0
ROUTE/BOX NUMBER H Fire Uumber -
CITY/,STATE U> / ZIP
T X19 N, Ra1~ W,
PROPERTY LOCATION:'W AL A;, Section
Town of W o,a,. St. Croix County,
Subdiviaion~ Lot number r a .
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' 's'ept'ic tank pumper. What you put into
the system can a ect the .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,
whic 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 'sys't'ems 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.
H
I/WE, the undersigned have read the above requirements and agree o
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed .d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration. date. l
SIGNED
DATE l 8 jD
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
I;A8Oli AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
PUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
L NO C~ATIO//~: ~ (li A ON: y OA SHIP/ICU' IC,IyALs OT A.: BLK*NO.: SUBQI ISI N NAME
/TZ- N/RAA (fir Or1~ iL// Il K //T~
COUNTY: OW R'S BUY R'S NAME: AILING ADDR SS:
le A) 54J
USE DATES OBS VATIONS MADE
NO. BEDR CO ER AL DESCRIPTION: ROV1
STS:
Residence ❑New Replace go,
o
(
RATING: S= Site suitable for system U=Site unsuitable for system 70C
O VENTIONAL: MOUND: IN GOS DU SYSTEM-IN-FILL O TANK: REC ME~NDEgeSYS~ M: ption
SS QUU S ou S El S SS U
If Percolation Tests are NOT required DESIGN tATE: [Floodplain, any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate:.? indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED S GHEST TO R _EQROC
F OBSERVED (SEE ABBRV. ON BACK.)
B--2 6,0 ' 9$,7s, > , v s z
77,
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IA{Qfi♦f`S AFTER ELLING INTERVAL-MIN. PE RI PE I Q [2 2 p PER INC
P- 3, to 3 s 2 e 2?
P- 3. 3 3 t. 3~ r
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. A
SYSTEM ELEVATION / 5 - '7 S
A 9,
N'. Mop I*
J Moog E1 /a0w'
~ PI _Q a7 = ~G ~7olt S~~S
J S. ,5r/p
f
~x.sfif~'~ ' 03 p ~6 ~ ~jviS~f 5ys~ s V6
i
CNJ,
o ;G
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 pri TESTS WE C PLETED ON:
iL N<Q~ /
ADDRESS-
AAJJ` CERTI ICA ION NUMBER: PHONE NUMBER (optional):
v >I ? P 00 y~/
CST SIG
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
LUM l~_~ 11;.
P F? C) ~J EC rr '
_
N A M E e1~rJ -,nN 1 N AM E--_j.)~~ I3c~s rt
L 0 CAT 10 N _ ..ls .S'..~_ . C E N S E = = 't~~ L--•--...
P L-0 I A-P
tF~
1f
.
• Dr(.y~r/j r r,) /1~.0 got S Are k' r.
r
fil e 1r<v C
---4 ,4
LJ
~ w
M .
FRESH AI1: IP1L~I;T3-AND OBSERVA114H PI-PE
CILO.SS SECTION
_ C Approved Vent Cap
r.
t Minimum 12" Above GStrp:
Final Gar
30 411 Cast Iron
Above PipeVent Pipe
To Final Grade* "
Marsh Ilay Or Synthetic Covering
Min. 2" Aggr.e11 _
over Pipe
Tee
Distributi~ Lr F-
Pipe
Aggregate _ Perforated Pipe [below
• beneath Pipe L,--coupling Terminat:i.ng r
' . ~ Rot tom of System