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HomeMy WebLinkAbout022-1007-10-000 -0 CD Q) 0 a o ° o M N N a a 0 N O O C 0 ~ cn c b CD c rn °o o y Y 4t) y U N C 3 0 ~ m N L c 'y I I N L X N Its o o N a y co N N C 0~ cyp N Z O O Q) y -D co c O O) N G) L O C C Z C X Z U- c 'S y y- LL c S a o 75 (D a E ¢ in xL> E ¢ CD 76-0 Q) U m M O (M CL a N N ~ E I ~ E I 00 to = o = o Z d m H LU a m a m M 0 O z c a°i z d ° c o E E -o ~ I ~ M I N a Q) Q> N O O N L N 0 d L C L O Z m z O :3 L) Z Z O N z r N o R w ~i 06 m a Y M a g o y N W d ►O. O N N d N O y O G a ° ° in a a o o w E U") t) t) N a i U) U) to rn WSJ ~ ~5 ° U) p a '~O Z •N a s a a s m v a • a I~' m 0) (n 0 c) CD U) -i U rn _rn rn rn c 'O r O O O (D CD N O a 0 c cD a`o ^ C O O O C O O 'O O N C D m N C d 0 00 ml N 'fl N O U 9 N N O o o R co 0 75 C O 0 N C N C u) a 00 N O N O 9 C O N O Co Q) 0) -e -E o o °O °O ° r N N V p 00 C f6 C m co 1 C6 (n y 0 C w Y M .F~a O r- co 0 =3 0 ° N o N m a o o o to y ML- C c N N C O O 0 m m O N O N O E ~ • o o Y Z y 2 2 cn c z y Z=3 2 cn t r~ xt Z = E v 3# c d a a ~ € a~ L IL Z. • a d m e m y c `I~i y E c- 3 c ~w 3 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION Ta_N-R--W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT I/ LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYS EM f-~*G.,, ZVI A2 mo'o` .B a sc,4 1,e INDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufac urer:Liquid Cap. Rings used: - Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: r No. of feet from nearest road:Front , Side, Rear Ft. From nearest prop. line:Front Side , Rear_,A,_Ft.- No. of feet from: Well 4 , Building:- 4~& - (Include this information in the above plot plan) (2 reference dimensions to septic tank SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity:' 21e44-1 z M- oz L Pump Model:Pump/Siphon Manufact.: Pno,ldl Pump Size ~ Elevation of inlet: -Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance fro,-,i nearest prop. line: Front-, Side, Rear_FtY--~ Distance from: Well ~J Building SOIL ABSORPTION SYSTEM 177ea),O Bed: Trench:- Seepage Pit: Width:- Length_ Number of Lines: Area Built _7{-- Exist. Crade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side , Rearj~Ft.-,Q No. feet from well .,4,P No. feet from building /,p HOLDIVG 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:. f(l PLUMBER ON JOB : LICENSE NUMBER: 6/90:cj 6 gfooo,317 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION Plan I.D. Number: 1~1SC}AI. WI 5~7Q7C 3,T 2 8 -R18 p State assigned) Town o of Ki•nnickin nic El J CONVENTIONAL El ALTERATIVE (If Hwy . N ❑ Holding Tank ❑ In-Ground Pressure Moun 47_ NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: IN ~T1Oyf~ATE, Dave Sobottka Rt.1, Roberts, WI 54023 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. L V.: CST REF. PT. LEVG / . I ~ . Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David Fogerty 3289 St. Croix 128763 SEPTIC TANK/ ' MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVF~t ~,y~ PROVIDED. : PROVIDED: I'S E , L,) re 606 9-410. 1 1 YES ❑ NO ❑ YES NO BEDDING: ENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING VENT T ESH ~I ALARM: FEET FROM LINE: ( AIR I ET ❑ ❑ NO L.,7 ❑ YES ilki NEAREST ~ 1" 0 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIRII9MMANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PR VIDED: ~yR.rS Ei?S ❑ NO (P/ v~83 S YES ❑ NO YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: IBUILDIKG: VENT TO FRESH (DIFFERENCE BETWEEN ~ FEET FROM LINE If ppg~ / / AIR INLET: PUMP ON AND OFF) I 5;e- ES ❑ NO NEAREST AV. OS 2_6 ?,ZS SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: / DIAMETER : MATERI AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN n 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 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N UMBER OF PROPERTY WELL: BUILDING: VENT TO FR BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: M LINE: AIR INLE NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM lope nd furrows thrown unstop : mound systems to make certain that it ON REVERSE SIDE. SHOW Cts YES ❑ NO r~rn meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; F- S 1 (I Q 5 ES ❑ NO C~rES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: p EDGES: 14,f q _ / " # ❑ YES G~IQ6~ ❑ NO CUES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: y It y DIMENSIONS ~Q r/~ MANIFOLD PUMP MANIF LD DISTR. PIPE MANJJ -OLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: / TCf $rE+^ea„~ PIPES: DA.: DISTRIBUTION 103.9Z -W-2k M3,82 HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION r~ of APPROVED PLANS 34 1 LWfE/ S ❑ NO Y_ svo- ❑ YES G ~ PERMANENT MARKERS: RVATION WELLS: NUMBER OF PROPERTY WELL: DING: COMMENTS: FEET FROM LINE: I f LYX s 0 OBSE ~P'S'ES ❑ NO NEAREST----* &0 If ~ f~ . Q. Q Grt~s Idea . ' .r 0 ~ rna,-) ~4oCr rise. L,;o e i'p T D " o ~V lam. ~'s 9s ' . ~5 :.pct:-. s. r. .R~~~o~ cau~,.e..d .ao ~.c,vc~•-~.a. c~.~,.~-'~ ~ ~~a.~-~. d~-~.~:.,~ A l I ain in county file for audit. SkbtA system on' Reverse Side. ;SIG:NAT RE: TITLE: I SBD-6710 (R. 06/88) ° ~dLHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~ _71 8% x 11 inches in size. El Check if revision top vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PR TY OWNER PROPERTY LOCATION S T,2p, N, R If E (or) 6D PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER I" 4r d Q 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ C LL GE • \ NEAREST ROAD Al A4 Al ❑ Public U 1 or 2 Fam. Dwelling-# of bedrooms 3 AR EL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) Q a~ _ &V 7 1 ❑ Apt/Condo W 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 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. Lv Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 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 [i ri/ 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 37 1.19 , L A 2, Feet Feet VII. TANK CAPACITY Site in gallons 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 {r r-1 El ri L= - 1:1 Lift Pump Tank/Si hon Chamber 'D O Cagg"k F1 F] . El I F1 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 Sta ) MP/MPRSW No.: Business Phone Number: - P4 vi! ff o z~ 9 3LS~ Plumber's Addr ss (Stree, ity tate, Zip ode): IX. OUN /DEPA MENT SE O LY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Ming Agent signature (No tamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determinati n 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 J 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 Nsubmitted to the coLinty prior.to installation. 5. Onsite sewage systems must tie properly maintained. The septic tank(s) must be pbn)ped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sevrage system, contact your local code administrator or the ` State of Wisconsin,. Safety & Buildings Division, 608-2663815. To be complete and accurate this sanitary permit application must include: I. 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 syVtem. 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 81A x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimens'.ons, 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 catfnty; E) soil test data on a 115 farm; and F) all sj ing 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 rnonitoripg, groundwater, ground- water contamiri'ation investigations and establishment of standards.'., SBD-6398 (R.11/88) t APPLICATION FOR SANITARY PERMIT 8TC-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 petmlt issuance, Should thle development be Intended got tesalt by ownet/conttactot,(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 Q Ccl 5l6 6,o77 " kd - Location of property AW-1/4 •=•-1/4• Section T_Z2__N-Rj~_d0_V Township k j A/ ~y 1 C Ir 1 Al Melling address f - 7I ~L~ y C2ab 7`5 w 6-yo z - Address of site Subdivision name Lot number Previous owner of property Total six* of patcel 14 ci 6 Date parcel was created Are all cornets and lot lines Identifiable? as _)I0 10 this property being developed lot resale (spec house)? Yes 0 Vot~lusie_and Page Number ~L as recorded with the Register of Deeds. 1-e~.~S~ir----------•---•---------------------------•--••-------•-•---- INCLUDE WITH THIS APPLICATION THE FOLLOWINGt A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and the SEAL OF THE REGISTER OP 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 Cet:tifled Survey Map, the Cettilled Survey Map shall also be required. 7 PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (out) knowledge; that t (we) am (ate) 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. 2.4 S4~z- • ; and that I (We) Presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to tun with the above 'described property, lot the construction of sold system, and the same has been dui recorded in the Office of the County eglster of Deeds, as Document No. -1 lignatuc of Owner 8lgnature of Co-Ownet (If Applicable) Date of Signature Date of Signature / 77- of wim"alm "Tom To qmoWt4Kr ' lot lim Tau Ker C.~. 2".2 f4wt r . "Vomo vJ* 1 IA. 19" . Tax eft. k_ sx ; 230 Y 19 j Titir Ilegide Raft Br of fiscaoais of ONiM"' f~ ' /1rt~aelsed uo/ef Sec. 7%,06 via. J 1w of it b mvl~' rsefli r~ 9 UM N ~5 a r Jebel W. tiller - O H z cn ' H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a OWNER/BUYER L~U idioGOT7~/~!~ ROUTE/BOX NUMBER 17 73 Hoy V eV Fire Number CITY/STATE_ l ZIP 'S-zld6 PROPERTY LOCATION:__&w 7 14, Section, T 2,ff N , R i g W, Town of k(~& A(Idkf•vv,a St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. 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 wast,ewater 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 to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ►0 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 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. DEPAR,TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDOS DUSTRY,- G DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969 N WI 53707 HUMAN RELATIONS (1-163.090) & Chapter 145.045) LOCATI'/~ / SECTION: ~/~~O E (or TOWNS ~P/MUNICIPA~~H L LOT NO.:BLK~NO.: SUBDIVISION NAME: COUNTY: OW LR'SIBUYER'S 'NAME: MAILING ADDRESS: / J AC~# c.~.t T ®1 USE r-- SP DATES BSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESC IPTION: (PROFILE DESCRIPTIONS: ER O ATION TESTS: L'!JResidence l- ❑New OReptace 6 _~e - fp RATING: S= Site suitable for system U= Site unsuitable for system S 2U CON~VENTIO: MD OUND: IN-GROUND-PRESSURE: SYSTEMS 2S -IN-FILLHOG TANK: RECOMMENDED SYSTEM: (optional) 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: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS re r° rr~I oaf BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH T ICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- y 9 ' B- L.S. B- Z fZ, S' DO r` e r 7,- B- ~ , B- O Le Sr SO B- 1'Zc s / w > fo r5~ tr af" PERCOLATION TES S " TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATPER INCH ES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD P- / U On S S If P P_ d 3 .z ' l6 P p_ e 3 rs / / %l / P ~ file 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 E : ~r _ I F- i - N i.- t(3_7S 1 3 flC fir= SAO R/~ t i f,,. ~ _ed _ 6 1 3 x'H 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. 9o r 1"W NAME (print): DAVE F E PLUMBING STS WERE COMPLETED ON: Licensed Perk Tester 4 Plumber /a ADDRESS: *113233 #3299 CERTIFICA ON UMBER: PHONE NUMBER (optional): Fo erty Heights Road R011IIIERT WISMNSIN U02-1 ~ Phone 749.3656 CST SIGN TUBE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - I INSTRUCTIONS FOR COMPLETING; FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1, Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be user] if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- t'if appropriate; 1t-1. ii,tormation (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box; 11, form acid place your current address and your certification number; 12, V Fe legible copies and distribute as rerluired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10„j BR - Bedrock cob Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone s S _ HGW - High C., U Q-id Pere r c; rned s - Sand W fs- Fii Bldg --ding Is I Sand > Greater Than sI Loam - Less Than I Lc Bn - Brown sii - Liam 81 Black Si Gy _ Gray *cl Clay Loam Y Yellow S-- Clay Loam Red I' Clay Loam n Mottles with sic - ` ty lay few, fine, fa nmo - { cc of . _ , rnrn m - Muck d p - t' niner~t HWI_ High water 1 •ral surface id VA " ;al BM Bench N/ VRP Vertic:' TO THE OWNER: TI, [ west T' t Ifi i;1 ll ;u ' t OPTIONAL WORKSHEET 1. MOUND SYSTEM II. IN-GROUND PRESSURE SYSTEM-Continued- 1. Wastewater Load, Total Daily Flow= gal. 10. Force Main: S? ? 7'J Use s. ILHR 83.15 (3) (c) Minimum Dosing Rate = in.~ Adm. Code and PROVIDE A DETAILED Diameter LIST OF SIZING ON PLANS. S~ 11. Total Dynamic Head: 2,5 ft. 2. Depth to Limiting Factor = ft. System Head = Z& ft. 3. Landslope = Vertical Lift = z f ft. 4. Distance from Dose Chamber to Friction Lou ■ ft. TDH = (7, 9 ft. Distribution System = S. Elevation Difference Between 12. Pump Selection: 7 Pump and Distribution System ■ ft. Pump w_il~dlscharp at least tipm at ft. total dynamic head. 12 6. Absorption Area Sizing: Pump model and manufacturer: O1iC w Area Required = sq. ft. JO a e - Bed or Trench Length (8) ■ ft. Bed or Trench Width (A) ■ ft. 13. Dose Volume: Trench Spacing {C) ■ ft. 10 Time' Void Volume of , , Z~~• 7. Mound Height: Distributbn Lines= / Gaily Wastewater Volume+ Fill Depth (D) _ ft. gal. 3 4 Doses in 24 hrs. ■ Fill Depth Downstope (E) ft. • L_ gati. Bed or Trench Depth (F) = ft. Backflow gal. Cap and Topsoil Depth (G) _ ft. Minimum Dose ■ Cap and Topsoil Depth (H) ■ ft. 14. Dose Chamber. 0,..~ 8. Mound Length: Volume = W' End Slope (K) Total Mound Length (L) ■ tt. III. CONVENTIONAL PRIVATE SEWAGE SYSTEM 9. Mound Width: 1. Wastewater Load. Tout Daily Flow ■ 1• Upslope Correction Factor= Use s. ILHR 83.15 (3)(c), Wis. Upslope Width _ ' ft. Adm. Code and PROVIDE DETAILED Downslope Correction Factor = LIST OF SIZING ON PLANS. Downstope Width (1) = Z- ft, 2. Required Septic Tank Capacity ■ gal. Total Mound Width (W) ■ ft. 3. Percolation Rate = min./in. 10. Basal Area: 4. Absorption Area Sizing: Infiltrative Capacity of Refer to Table 2 in e . ILHR 83 Natural Soil = gal./sq.ft./day. and PROVIDE A DETAILE IS't OF Basal Area Required= sq. ft. SIZING ON PLANS. Basal Area Available = 0 sq. ft. Required Area = sq. ft, 11. If Standard Tables from Chapter ILHR 83 Length ft. Width ft. are".used, indicate Table # ` 12, For the Distribution Network, Use Numbers 5-141n Section 11. Number of T ches = Trench Sp ng = ft. 11. IN-GROUND PRESSURE SYSTEM .B S. Oistributio ystem: 1. Depth to Limiting Factor = 3 ft. Late Length = ft. 2. Landslope = % N ber of Laterals = 27 min./in. atera1 Spacing = In. 3. Percolation Rate = G in. : ft. Distance from Sidewall to Pipe = 4. Proposed System Elevation 1az 5. Wastewater Load. Total Daily Flow: 41s O - gal. System Elevation = ft. Use s. ILHR 83.15 (3)(c), Wis. Adm. Code and PROVIDE A DETAILED 1 SYSTEM-IN•FILL LIST OF SIZING ONTLANS. Fill in All Items from Section Ill Required Septic Tank Capacity = 0 O gal, 6. Absorption Area Sizing: V. SEPTIC TANK= ~ooC gal. Percolation Rate = 2 min./in. 1. Capacity KS ~b11 Area Required = 3~b sq. ft. 2. Manufacturer: System Length = ft. 3. Show Site Constructed Tank Details on Plan System Width = ft. VI. DOSING TANK 7. Distribution Pipe Sizing: Y4 gal. Hole Size = in. 1. Capacity = t , ~ Hole Spacing 3 ft, 2. Manufacturer: Lateral Length • ft. 3. Pump Manufacturer: Lateral Sizein. 4. Pump Model: 0A a s ft, S. Operating Head= a~ ft. Lateral Spachtg - in. 6. Flow Rate= ` 0- r Uiaanct+ from lidcw.di .141 1 ipe ( K. Dtstribution Pipe Disch trge Rale: 7. Show Site Constructed Tank Details on Plans Number of I loles Per 1'ipe ' ' I low Per Plitt gpm, VII. HOLDING TANK' ; 9. Manifold Siting: 1. Capacity TYPe (01111111ki or end) • 2. Manufacturer: a nxtructed Tank Details on Plans Length it. Diameter in. -SHOW ALL INFORMATION ON PLANS- t DLLHR SBD-6761 (R.03/821 (1-7) N &1/ 10. i-d t r~tEA ` TuE . N1cow3o VS ia~tA,IN ~wcx5~v~~ED ,r 2 ~ i ✓ X17 13.L- ~ C3 3 KSi 7~in 10% 7Ur 8~ ►o Ac O ►a, `f7~ Ter. ~o )pC7~ ~9 S41, r1ip ;za I~ ee, ® L40 E ~1 5p`~ ern AO p 7HE ExisrtwG Semc -Cb* v- woST 5E tt3SPK'rEr> /1i'~ f-c srt~ v c; is , c7u ► Ess, s~,i.►~ atr-FLE:S A.tsc) Mi7ST.::~E RENAiRtii~ c~Vz MaD~FtED t>: 1.{~GEhb,~`{ - For--c,614pwm"cE W(CH. 144R ~3 ! W 'A" G. wp,OE$YS-~~~11 RECEIVED iop.a JUL 1 8 1990 pY SAFETY if BLDGS. DIV. IONS , p~10 till 6-7 d~pAaTMEt - J~~,e/► WJ, ~~.t~Ct $ a~r b s P~ E a - lo; 50, m~~l Zg ` 2 ~ s x~ Obs~~-~}on ~ Z~ W, V?- c.s Page Of Straw, Marsh Hay, Or Synthetic Covering Distribution Pipe Medium Sand . H G Topsoil F 3 E „ p AGE . E SCW • t % Slope OjIfiorta Bed Of = 2 Force Main Plowed Layer . ONSA99regate EI,A11 . AWg Ac~a 0 _L Ft. OEPARIME pF , cd C90. ction,Of A Mound System Using E .3 Ft. CC,~ESE;~ A Bed For The Absorption Area F • ~y Ft. SE.E 6 / Ft. A Ft. H _ Ft. Signed: B.Ft: License Number: rA o(L,5c0 3 z8y K Ft.- Date: G- z 3 90 _ L (0 7 Ft.' Ft! I 1Z_ Ft: W ZA, Ft. - L - )bservation Pipe S , -B K A ~ . _ Force Main W Distribution Bed Of 2 %Z " Pipe Aggregate Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area - z. Page _ Of _ Perforated Pipe Detail • ,0 End View )Perforated and cap PVC Pipe News Located On Bottom. e S Are E4qoNy 111wed INI - t "~~7t? i ~ p1~~ tt13MA~ `ti Last Noie Should Be . s ; Neat To End coo Distribution Pipe Layout P ~15 Ft. • . S 7 r" X ?(o InchPS r Y _ Inches Signed: Hole Diameter Inch Lateral l yz Inch(es) License Number: mPyt-s ,9ZB9 Manifold = Inchesr Date : Force Main " = Inches, # of holes/pipe Invert Elevation of Laterals gj: Ft. PAC, I: C:F PUMP CHAMBER CROSS SECT ION AIJD SPECIFICATIONS VEUT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING MAIJHOLE COVE JulJCr►oU aox I 25' FROM DOOR. 12"MIU. WIIJDOW OR FRESH AIR IMTAKE I GRADE I 4"MIM. t ~ Ib"rrlN. COIJDUIT-- - - - ONISITE SEWAGE IC . J I ICI LE T AI GHT SEAL D~ I I v . " ti;" I t Iaw% nr 1ti 1 ;,''+'Oi2Ci6~Lt?hL(x I III APPROVED JOINTS APPROVED JOINT ti :A I I I ALARM W/C.I. PIPE W/C.2. PIPE' I I I t EXTEWDIAIG 3' EXTENDIUG 3' i II ONTO SOLID SOIL 01JT0 SOLID SOIL RE TIONS I PARTMEN' F iY' dUH ANN HUM I t OIJ N OF SA 1Y e~ ELEV. FT. SLE COI; SPU tiCE . PUMP OFF D CONCRETE BLOCK RISER EXIT PERMITTED OWLH IF TAUK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPEGIFI'CATIOKJ DOSE- TANKS MAWUFACTURER. IiLwi~1UfABER OF DOSES: PER DAH TAMK SIZE: g O~ GALLOUS, DOSE VOLUME ALARM BACKFLOW: GALLONS,-' ALARM MAIJUFACTURER: " MODEL I.IUMBER: ) I' CAPACITIES: A=. INCHES OR rALLOWS it B= IMCWES OR ALLDK~IS SWITCH TYPE: C~ it PUMP MAUUFACTURER: l G = _INCHES OR GALLOWS MODEL KIUMBER: D=1.--IMC14ES OR AAM3 GA54oU~'s~"" SWITCH TYPE: 0) YC lMV MOTE: PUMP AMD ALARM ARE TO BE MIKIIMUM DISCHARGE RATET GPM ' INSTALLED OU SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTIOU PIPE.. FEET 80O I + MIMIMUM NETWORK SUPPLY PRESSURE . . . . . 2.5 FEET +15~r~ _ FEET OF FORCE MAID X ~ F/oo►tFRICTIOU FACTOR. Z FEET it, `-00,%A:t• TOTAL DyKJAMIC. HEAD FEET IMTERLIAL. DIMEIJSIOWS OF TAUK: ;WIDTH z ;LIQUID DEPTH -,L SIGNED: LIC,EPSE IJUMBER: ~L DATE: r Submersible Effluent Performance Curves Pumps MODEL 3885 25 eo SIZE 3/4 Solid 20 - E-v 16 50 b • 10 30 d 2q 0 0 0 .10 20 30 .0 Vii: 6D 70 !0 20 100 110 120 am 0 10 20 30 09A CAPAWY GOULDS PUMPS. INC ' WWA WUS 1/W 0w 12ZT71" 120 MODEL 3885 SIZE %4 Solid t1o I 30 100 _ 00 °o_. 20 70 I 10 16 so 10 30 ~ 20 <t a Z 10 c11 ° 00 10 20 30 .40 SO so 70 w 90 100 110 120 am 0 10 20 30 W& . CAPACITY . tiaw,M+3 /w ~tNi :1cs~tvl~ /ti~pb M!~: e 1 /ct1 ST. CROIX COUNTY WISCONSIN h ylt : 3 47 01 ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 June 18, 1990 Divison of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 Dear Sir: An onsite investigation for the Dave Sobottka property, located at the NV,- of the SE4, of Secion 3, T28N-R18W, Town of Kinnickinnic, St. Croix County, revealed suitable soils at a depth of 36" below which seasonable high ground water was noted. This site should be suitable for a mound. Since ely, mes K. Thompson Assistant Zoning Administrator cj 1 Mound system for Dave Sobottka NE4 SE4 S.3-T28N-R18W Kinnickinnic, township St. Croix County pages #1----------plan approval application #2---------- St. Croix County verification of soils #3----------Soil data (115) #4----------plot plan-plan view #5----------work sheet #6----------system cross section X67----------pipe lateral layout #8----------dosing chamber #9----------pump curve Dave Fogerty Fogerty Heights Roadfi Roberts, Wi. 54023 MPRSW 3289 6-23-90 _ STATE OF WISCUNSIN UILMN DIL~F~ PRIVATE SEWAGE SYSTEMS CrvISIONOFSAFETY SBUILDINGS _ BUREAU OF PLUMBING PLAN APPROVAL APPLICATION i o. Box W"Na »s ~adl ewi 53707 ooB-sans .STRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration. Document Sales, 202 South Thornton Ave., P.O. Box 7840, Madison, Wisconsin 53707, Telephone (608) 266-3358. 1. PROJECT INFORMATION (Type or print clearly) Revision To Plan Number: Name of SuOmitung Party (Plans returned to same) Project Name Dave Fogerty mound Street 8 No. or Rural Route Pro jct Loeption - S e N Description Fogerty Heights Road NE%--- S.~~T~Lts1~=° City or Village State Zip City County Roberts, Wi. 54023 Village OF: innickinnic St. Croix Town Telephone No. (Include area code) &15-749-3656 Oesigner Telephone No. (Include area code) Owners Name Telephone No. Include area code) n/a Dave Sobottka 715-425-5898 Street 6 No. Street d No. R.R.#1 City or Village state Zip City or Village State Zip Roberts, Wi. 54023 2. APPLICATION FOR: ENew Mound System (3a) ❑ Groundwater Monitorinig (7) ❑ Conventional System - Public Building (1) Replacement Mound (4a) C.1 Holding Tank (2) Replacement Pressurized System (4b) ❑ System in Fill (1) ❑ Petition For Variance (6) I New Pressurized System (3b) Q System In Flood Fringe (1) G Other Alternatives (5) P, FEE COMPUTATIONS (Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO DILHR 3a. 750 - 1,500 gallon septic tank - 50.00 4a. 50.00 3b. 1.501- 2.500 gallon septic tank - 60.00 4b. 3c. 2.501- 5.000 gallon septic tank - 80.00 4c. 3d. 5,001- 9,000 gallon septic tank -100.00 4d. 3e. 9,001 - 15,000 gallon septic tank -150.00 4e. 3f. Over 15,000 gallon septic tank -250.00 4f. 3g. 500- 1,000 gallon dose chamber - 30.00 4g. 30.00 3h. 1,001 - 2,000 gallon dose chamber - 50.00 4h. 31. 2,001- 4,000 gallon dose chamber - 70.00 41. 3j. 4,001 - 8,000 gallon dose chamber - 90.00 4j. 3k. 8.001 - 12.000 gallon dose chamber -110.00 4k. 31. Over 12,000 gallon dose chamber -150.00 41. 3m. 500- 5,000 gallon holding tank - 30.00 4m. 3n. 5,001 -10,000 gallon holding tank - 55.00 4n. 3o. Over 10,000 gallon holding tank -100.00 4o. 3p. Revisions - 20.00 4p. 1111111111035q. Groundwater Monitoring Per Lot - 32.00 4q. (other than a proposed subdivision) Subtotal 0.00 3r.. Priority plan review: walk through 4r. Submittal of plans in person. by appointment. with double fee e7 f 3s. Petition for variance "e Setback - 25,00 4a. Site evaluation - 50.00 Total Fee 80.00 NOTL• Fe" prw" to WN. Adm CeN, Chattl iron/. a san."m in Ilrasl in" be MONO w Chan" ann"IV - s ST. CROIX COUNTY WISCONSIN b xy.'rS.~` 1 ZONING OFFICE y,'s4ii `~r...; ;':t,_' 1•£;'.1;3 . ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 June 18, 1990 Divison of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 Dear Sir: An onsite investigation for the Dave Sobottka property, located at the NE4 of the SE-1,- of Secion 3, T28N-R18W, Town of Kinnickinnic, St. Croix County, revealed suitable high ground soils at a depth of 36►~ below which seasonable water was noted. This site should be suitable for a mound. SSince ely, es K. Thompson Assistant Zoning Administrator cj v _PARTMENT OF f EPC' ~ J ON-SOIL BORINGS AND SAFETY & BUILDINGS !►?TRY, DIVISION ; AND Li ~ "0" 1~ ; T (115) MADISON WI 53707 HUi~1AN RELATIONS (1-163.0301) & Chapter 145.045) I t)CAllu'TJ; S-` CT 10 N: TOWNSHIP/MUNICIPALITY: T NO.: BILK. NO.: SUBDIVI ION NAME: 4"L 4 COUNTY: 1 OVIN R'S UYER'S NAME. MAI LING AUUHESS: USE (0- 3- j DATES BSERVATIONS MADE r W. BEDRMS.: C-0-M-M-ERCIAL DESC IPTION: TESTS: 717UME DESCRIPTIO7470LATION r~ ' Residence ❑ New lieplace O F?rl i'I;JG: S' : st? suit hi.3 fer s}s.am U° Sits umuitsbt^. fer sy~'tacn 1'i? dv< Iiltrj~it : hfOUh;t): IN Gf ~ils`tGfiiE' '+JFiE: SVgTTL- ~'f tt t'' llC }l [;5j_ TANK: RECOMMENDED SYSTEM:loptional) ~0' CLU 9 S EA 0 S DU El S 2U LiS ❑U , If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: ( Floodplain, indicate Floodplain elevation: PROFILE DESCRI'TiORIS fr• yl' pp~ BORING TOTAL LPIH I GR UidJ1`JA'rEE tNfFi%S L fir~.FiArT tii0~ SOIL WITH T ICKNESS, COLOR, TEXTURE, AND DEPTH ',Al-'ER DEPTH IN; ELEVATION OBSERVED EST. HQHE5T TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) _ rss-r( r B- L.S. B- 2- /1, 9 D . / c B- o L S. > 5-0 B- 3 v r B- T2c s > So L.S_~8,,ic PERCOLATION TES S TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER INCH P. V d S" S P- P_ 2 .3 42 P- P- - 3 a / 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 Ze • l C l i - - fcah gyp= To l 41 i 'PI amv~r 14- 74* i _ - - - + - fCs•W~~ ;.S"hat f f _ 17. 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): DAVE FOGEM PLUMFLN STS WERE -COMPLETED ON: Licensed Perk Tester & Plumber /0 1r_ ADDRESS: 211"3 tt CERTIFICA O UMBER: PHONE NUMBER loptionalF Fo. ert~i Iiei hts Road Phone 749.3686 CST SIG TUBE: 'W7 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - ~j 1 n AS BUILT SANITARY SYSTEM REPORT 1ER C, Al-0- , TOWNSHIP SEC. V 7 T ±9 N, R / W .0. ADDRESS , ST. CROIX COUNTY, WISCONSIN. I 'BDIVISION , LOT LOT SIZE NWY PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N O7 I "'TIC TANK(S) Q©C~ MFGR. ) C NCRETE STEEL NO. of rings on cower Depth DRY WELL t:NCHES NO. of width length are no. of lines width length area / d to top of -pipe 1REGATE l~l -g RATE AREA REQUIRED AREA' AS BUILT cclaimer: The inspection of this system by St. Croix County does not imply complete 1pliance with State Administrative Codes. There are other areas that it is not possible] inspect at this point of construction. St. Croix County ass es no liability for tem. operation. However, if failure is noted the County wi make every effort to _-.ermine cause of failure. -'ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST "INSPECTOR DATED tis 2j PLUMBER ON JOB LICENSE NUMBER Z REPORT ff INSPECTION-INDIVIDUAL SEWAGE SYSTEM San.itaxy Pexm.it. State SPpt.ic ; NAME _ . " wndhi p St. Cno.ix County Locat.ioia lt,~/,j r , ( Section SEPTIC TANK Size Zoo ~ gattons. Numbers o6 Compaxtment,6 D.iatance FAOm: WeZ.- J f 6t. 12% on gxeateA .6 tope Bu.itd.ing k1 it. wetZands ~ . H.ighwaten _ it. DISPOSAL SYSTEM D.i.atanee Fnom: Wet it. .12% on gxeateA Atope Bu.itd.ing~it. Wettands Ft. H.ighwateA it. FIELD DIMENSIONS: Width o j txeneh~it. Depth o j Ao ek b etow t.ite .in. Length o6 each Z ine S~ it. Depth o6 xock oven t.ite Z .in. NumbeA o6 Zined Depth o6 tiZe below grade e f--in. Totat .length ob t.ineA /fi~ bt. Stope of txeneh in pen 100 it. D.id Lance between Z iness_6t. Depth to b edxo ck jt• To.tat abso)Lbt.ion aAeal~00 6t2 Depth to gxoundwatek 4"wit. Requited axea it 2 Type oj Covex: Papen ox Stxaw •f PIT DIMENSIONS: Numbvt og P" t6 GAavet axound pitz yea no Outside diamete S Depth below inlet it. 2 6t Z Totat absoAbt.i n axea A AAea quiAed it2 e A e7 INSPECTED BV TITLE -APPROVED DATE 197-2. REJECTED DATE 197 i I I EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES "15 , [VISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: NW 5-E-/,, Section 3 T28N, R18_ IIIIIIIIIIIIIIIII!W, Township or Municipality KinnicKinnic Lot No. , Block No. Subdivision Name County Saint Croix Owner's Name: David Sobottka Mailing Address: RR 1, Roberts, WI 54023 TYPE OF OCCUPANCY: Residence XXX No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT XXX DATES OBSERVATIONS MADE: SOIL BORINGS May 24, 1979 PERCOLATION TESTS Mayes, 197() SOIL MAP SHEET Number 76 SOIL TYPE Nicki n silt loam PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- 1 36 18" sil Ts, 10" sil, 8" is b-ni 20 no 30 1 7/8 3/4 40 P- 2 38 15" sil Ts, 18" sil, 5" ls- br 20 no 30 1 1/8 1 1 30 P- 3 42 20" sil Ts, 20" sil, 2 sl brn 20 no 30 1 1/4 1 5/16 32 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B 1 72 none > 72 18" sil Ts, 10" sil, 23" is brn, 21: brn s B-2 74 none 7 74 15" sil Ts, 18" sil, 12" is brn, 29" brn s B-3 78 none > 78 20" sil Ts, 20" sil, 14" sl brn, 24: brn s PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of syitable areas. Indicate yber of square feet of absorption area needed for building type and occupancy. 900 ft trench, 1_2S ft he Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. C d _ Io to drive. wy R eene 49 le at'on oo' A ex sting 3 ed oo 1 " N an Sc le l" • Pe c es s ■ Bo a of s ex'st'n . Po nt well S ct on 3 1 R 2 Of gnnandi y certify that the soil tests reported on this form were made by me in accord with the procedures the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) Roger A. Swanson Certification No. 55-606 Address RR 5, Box 124, River Falls WI 54022 Name of installer if known Unknown CST Signature '4411442= COPY A -LOCAL AUTHORITY State Permit # ~ °2 PL-867 . ' State and County I Permit Application County Per # ~ for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 1) ON" 1/1 •&W- -5-0 AZV7r±X et OP? 1119 B. LOCATION: Y4 Section 2, TA`N, R E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family _X Duplex No. of Bedrooms .3 No. of Persons_ D. SEPTIC TANK CAPACITY 1000 -Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete QC Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement A_ Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area >2620 sq. ft. New Replacement X Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Lengt Width 2 A/' _DepthZe Tile depth (top) No. of Lines Al Seepage Pit: Inside diameter Liquid Depth -No. of Seepage Pits Percent slope of land 6f Distance from critical slope WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Teste , NAME p S1 ep, C.S.T. # Ss-GO C and other information obtained from Xi (owner/builder). 04 1 Plumber's Signature MP/MPRSW# 41'V -C Phone All O/ Plumber's Address LEE" PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. i , G ~ t a Y)t S-o r m€ D ' , Etc ~ ~O_ t Do Not Write in Space elo FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application 7 Fees Paid: State Ao DO Coun y ? QQ Date 917 5? 11 Permit Issued/$8 (date) / Issuing Agent Name Inspection YesNo State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, RO. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78