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HomeMy WebLinkAbout030-1070-50-000 3 0 r O v). o~ ~o M N 0o a o ~L X N C ~ f0 O O O) Ct O y+ O_ N L 'n •3 o z LL O O'D Q Ma I, 3 N N Z i6 E J ~ = O N I- C', 0 C7 € m C O O Z ,::t U c V p 0 a> Z c fn F- rn U z c -a ~ m II ~ ~ o N a) N C • N j a U ~ O p O z Co Z w Z N c C ~ N 7 t: y ~ U N Lo N m L N N O CD _ C N C G a -0 `y am N ~U) U) U) ~ao o Zo a Laaa U (V O O 7 O N y (A J U Z rn m } 10 ? > N 0 O Q O _ O 6 E = O r 7 i ~ N d r m 0 O _ d Q > Cn H H ~ ~ o r~ C M N C O RS Q W O ! C O d O 0) O CL CL a N = a N ~ N m Q) O O N C $ O C 3 d' a N N y 0 N U r w U n d V) G+i O O C LO Y O F•-' C N O N E U O ~ O U) r O Z c fn a O • ee a d I `m a A V a 2 0 U) o Parcel 030-1070-50-000 02/14/2005 08:13 AM PAGE 1 OF 1 Alt. Parcel 26.30.19.253E 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * JOHNSON, PATRICIA A TR PATRICIA A TR JOHNSON 761 140TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 761 140TH AVE SC 3962 NEW RICHMOND SP 8040 BASS LAKE REHAB DIST SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE SEC 26 T30N R19W PRT GL 4 COM W 594 FT & Block/Condo Bldg: S 82.5 FT FR NE COR NW NE, W 132 FT, S TO LK, SELY ON LK TO PT S OF POB, N TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) POB 26-30N-19W Notes: Parcel History: Date Doc # Vol/Page Type 06/29/2004 767235 2605/308 QC 07/23/1997 556/108 2004 SUMMARY Bill M Fair Market Value: Assessed with: 5322 281,800 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 165,300 111,900 277,200 NO Totals for 2004: General Property 0.000 165,300 111,900 277,200 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 87,800 89,300 177,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 118 Specials: User Special Code Category Amount 040-OTHER ASSM'T SPECIAL ASSESSMENT 515.02 Special Assessments Special Charges Delinquent Charges Total 515.02 0.00 0.00 Form- STC- 104 AS BUILT SANITARY SYSTEM REPORT ' `ONNER`rIC~=-J7t:~•cl ~.arl~l TOWNSHIP SECS ' T N-R W . ADDRESS 4,x AJA7_ ST. CROIB COUNTY, WISCONSIN + SUBDIVISION LOT LOT SIZE PLAN VIEW :t. • , Distaisces and dimensions to meet requirements of 11UR 83' SHOW,EVERYTHING WITHIN 100 FEET OF SYSTEM .:t . is 1. „ 1 _ ~ i . r i y:'r'~ `>:~r~ w 11 1, ` ldtJS/~ r Van _ _ • ; INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference points Proposed slope at sites SEPTIC TANKS Manufacturers 0 iquid Capacity: ' "-'-Number of rings useds Tank manhole cover elevation: • Tank Inlet Elevations Tank Outlet Elevations"•.' Number of feet from nearest Roads Front,O Side Rear, O- feet • From nearest-property line s • Front.0Side,ORear,~ feet Number of feet from: well building: (Include this information of-the above plot plan)( 2 reference dimensions to septic tank) SEE, REVERSE SIDE PUMP CHAMBER Manufacturer: _ Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom af_tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: • -Number of feet from nearest property line:'r'• Front, 031dao O Roar, 4 Ft.__ 'Number of feet from"rll: Number of feet from building: (Include distances.on plot plan). SOIL ABSORPTION•SYSTEH _ Bdd:- X Trench: . Width: t Length:; Number 'of Lines: Area Built: Fill depth to toj of pipe: ems-. „ . Number of feet f~om nearest property line: Front O Number of feet from well: N Aber of feet from building: (Include di tances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: f Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (C eck one). • i HOLDING TANK ! Manufacturer: Capacity: Number of'.rings usad: Elevation of bottom of tank: • Elevation of inlet: . Number of feet from.nearest property line: Front, O Side, O Rear, ft.- Number of feet from well: Number of feet from building: Number of feet from.nearest road: , Alarm Manufacturer: ~i _•a Inspector:. Dated: Plumber .on job: s v-- s 'i i License Number: 3/84:nij DEPARTM!NT 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 NWky., NE 4 , Sec . 26 , T30-R19 CONVENTIONAL ALTERATIVE Sf a assigned) 'Number: I~ ❑ Town of St. Josepl}-T Ot -LT'Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: B M K ermanent re ~39e,e point) DESCRIBE IF I RE A REF. PT EV.: ST REF. PT. E / Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Calvin Powers Jr. r~ 1563 St. C 'x 135504 SEPTIC TANK/HOLDING TAN •f, 4- t'Vl," = O/6® -7• MANUFACTURER: LIQUID CAPACITY: TANK INLE LE j TANK OU ELEV/: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: d',(„ aW ~ ~-5 COrK ()W ~s 9, a$ C2iYES ❑ NO DYES NO BEDDING: V&W -DIA.: V9W_MATL.: HIGH WATER IINUMBE OF ROAD: PROPERTY WELL: BUILDING: VENT T MESH V 4L i- ALARM: FEET FROM LINE: AIR 1 E ❑ YES NO -U ❑ YES NO NEAREST DOSIN CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTR RATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ YES ❑ NO EAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LE DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continu CONVENTIONAL SYSTE 9 f V-5tefvt' 6e WIDTH: LENG O.OF DISTR. PIPE SPACIN COVER INSIDE DIA.: # PITS: BED/TRENCH LIQUID TRENCHES: / MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE AT RIAL: NO. D STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH I S: AB COVER: E EV. INLET ELEV. END: VG PIPES: FEET FROM LINE: t / AIR INLET: BELOW P~€ G y S I ?Ivl-~-a73sT NEAREST-~ CA) MOUND SYSTEM: Mound site plowed perpendicular 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 T PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPT VIER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL PTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: N ISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPE DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CO PONDS TO INFORMATION PR ❑ YES E] NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST----00' 3 - ~r-rw~ c r r~l~m P awls ~ f"2~Q Sketch System on t n in county file for audit. Reverse Side. SIGNA RE: TITLE: j SBD-6710 (R. 06/88) FI Sf Awl Lc~ i r ~w \ it \1 O \ i N " x~ 1% Q. ii k x b~ 4 4'0. 1 ! 4. G ~ 1 ~ W ~ 0 f A t` P V 1 t 4 i ly r tly~ rAX k e i I ~i ~r , f a y, S cr { r l* •d. r ~ tf ~ , s.....-. ~a.. w t_ n a. ~ ` n.. ° ~ ~ to ~~T` ~ 4 f - _ N `MC B ~ ! ~y a„ 4 N t Qk. f i Iu r E SANITARY PERMIT APPLICATION TY 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 Q it Bevis-ion, to previous app ication 8'/4 x 11 inches in size. ❑ -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY L CATION '/4 t/4, S T , N, R E (or PROPERTY OWNER'S MAILING AD RESS T# BLOCK # CITY, STA ZIP CODE PHONE NUMBER SUBDIVISIZAME OR CSM NUMBER az 7/r Z01- II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE : NEAREST ROAD ❑ Public ~Z1 or 2 Fam. Dwelling-## of bedroo AR L TA NUMBER(5) V 3~ _ to -7~` _ a III. BUILDING USE: (If building type is public, check all that apply) ~5.~ ~ V V GU 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4.E] Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 420 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./'nch) ELEVATION Feet Q Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Se tic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum is ame (Pri PI er' Sign re: o mps) MP/MPRSW No.: Business Phone Number: /vO Plumb is Add ss ( treet, City, te, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuin Agent Signature (No Sta sv Surcharge Fee) Approved ❑ Owner Given Initial / (4~ _ S Adverse Determination ` X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber f 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: f. 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. I 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) a • APPLICATION FOR SANITARY PERMIT , 8100 C 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 f f a~ Location of property ~TU- 1/4 &LL114, section T N-RZ V Township Hailing address -3 ;2,~F Sa vcz 9 Lt~r~z -:'-1 I e, „mil yw~ w Ss'// 7 Address of site API° i j 30/G 8ubd1vIaIon name_ fU'iq- Lot number . Previous owner of property Total size of parcel _ N/A Date parcel was created /5' Are all corners and lot linea L entifiable? _ ye8 _iNo Is this property being developed for resale (spec house)?_Yes X No Volume ---and Page Number D as recorded/wlth the Register of Deeds - INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT.NUMBER~ VOLUME AND PAGE NU)(B$ R the BEAL OF TH and B REGISTER OF DEBDS. In addition a certified surve available wo Y, if , uld be helpful so as to avoid delays of the reviewing. the deed rocess. If d description references to's Certified Suzve Ma p Map shall also be required. Y P. the Certified Survey f. - PROPERTY OWNER CERTIFICATION I(VeY certlfy that all statements on this form are true to the best of m knowledge; that I (we) am (are), the owner(s) of the property described In this information form, by v4rtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ~r~990 and that I (We) f 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 Bald system, and the same has been dul recorded in the Office of-the County Register of Deeds, as Document No. 3 Signs re o Owner , , Signature, of Co-Owner (If Applicable) a Date of Signature Date of Signature iL .~`L} r+ `7k t~' - ~W`~r~•' ti . '.ti•` «{fit`. N'V kv7_t; Vit . ~`TM,4.y *h. k~}{9/:Y ~F~y!S.n.~"`.y ~~'t q ~~sej~+~4~Y,=~ t~f~`. [It.. "I 16t 50 77, is id4"' 4 - r ~ly tr v' 'i. a ~ - y sll i t d t~ r 9•a ~k ,i.. , ~ a! I&A • cam,; «~7!-. , il. pp.. pt s t" fs aoW tomd to Aotit~ "X. } a~ •F 1 I t - *A s' p ibi Q~k 'o, cou ~ v t 3 ~ y ~ tit i • Jilt h luo . i' t Yf; c c. r.. ,K' f la f,~B a r, c ~C~na LLauuo0,0 saWPP X27-6t 97, is v tea,, iq pajodwoe q 13" PUD aai,};o Aw u! Pjoo°j }o puc !IU ^lop 0 paUw Puo aru4 ~ ~ q p~u~ru~ut ~N ~,~pua ~tga»y 1 xp~ to Mw~? upo"M to *jolt STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER -TO k y,-S ft)--- ROUTE/BOX NUMBER 3~ S4 v4~ FIRE NO. CITY/STATE S4 mow/ ~1'L S511 7 ZIP PROPERTY LOCATION: AJO) 1/4 1/4, Section , T~0 N, R__Z_I':;' W, Town of -_I D e iD St. Croix County, Subdivision Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE Ste- d- St. Croix County Zoning Office' St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address 'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS . `INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 N WI 53707 HUMAN RELATIONS ULHR 83.09(1) & Chapter 145) LOCA'/ N: SECT10~T3 N/R (or T~~S~HIP ~NICIP LITY: LOT N .:BLK. /T= ION NAME: AIAI C NTY: OW R BUYER'S A E: MAILING ADDRESS: , S" Z';/Ul- . Z,,jz A~~tZ USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCI DESCRIPTION: PROFILE DESC IPTIO S: PER O ATION TESTS: Residence [ea New ❑Replace - RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMEND2"4Y4 STE : optional) ©S DU ®S ❑U ®S ❑U ❑S CCU EIS 2U d If Percolation Tests are NOT required DESIGN FATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: S I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS - BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF OIL W TH THICK SS, COLOR, TEXTURE, AND DE 4TH NUMBER DEPTH I'M OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- - ? - B- s- o.4 s ~ ee.c~eku/s - 6- S), eq Z o- Lo- , 3 B- - 3 .!3 B- PERCOLATION TESTS fGt' TEST 4DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERLOU 2 PER] 3 D PER INCH P P_ /S P- / 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. ~e~-c✓~b SYSTEM ELEVATION + E E + E i A 40 + 3 N a ~ + 3 t I E E E E 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 rint : TESTS WERE COMPLETED ON: VIA J '0 ADD SS: CERTIFICATION NUMBER: PHONE NUMBER (optional): dL AL~ CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - l INSTRUCTIONS FOR COMPLETING FORM 115 - S BD - 5395 To t a complete and accurate soil test:, yor.rr report Mast include: C: -,p lanai descrivation; 2, The use snet.iorr rnr.rst clearly i v, ethei this is a resiiderice or" commercial projer.t; 3. MAXIMUM number of ~droorns OrnfflerCial use planned; 4. Is this a crew or rein', ~ - t system; S, Complete the suitah=r -...rill boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTE€ 17) -R RULED OUT BASED ON SOIL- CONDITIONS; 6. PLEASE usethe abbreviations sh :in iii=re for writin , ,r r:,pions and completing the plot plan; 7. MAKE A LEGIBLE diagram a(,(. "sly locatin g yG t ( is. C?;aGVIng to scale is preferred. A separate sheen maybe used if . <s , 8, Make sure your benchmark ar, gal elevatio i ref ~ ioin =+e clearly shown, acid are permanent; 9. Complete all appropriate boxes to dates, parr -e as, flood plain data, percolation test exemp- tion, if appropriate; 10, If the information (such as food plain, elevation) r?L~ , ;iot apply, place N.A. in the appropriate box; 11. Sign the form and place your current addiess and your certification number; 12. Fake legible copies and distribute as required. i- l' SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF CC TION. ABBREVIATIONS FO:' FIEF SOIL TESTERS Sail Separates Textures Other Symbols st. Sta.)rse {c~ ~1, 10"j B13 Bedrock cob Cobble ~'3 - 10") SS - Sandstone gr Giz, idei 3") LS Liwt-,stone S FiGVV l ' r C~rc °r~r?tcr Pera: 3 to ry" Im L :irn sir, L, ar-n Inot tles s sic - Si f <viay fff few, fine, faint "c _ Gray cc - common, coarse pt Peat nlrn - Maoy, medium ,it - Muck d - distinct: ri r>rornlne3 HWL High--, Six general sail textures sur§a: for liquid waste disposal BM - Bench N, irk VRP Vertictai Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be SUbMitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. i J f=j I T- ' I I i 1 4 _ 7 ' ~ j i I I ~ 1 1 1 1 1 I ' I -T- -T _ - I I - ! I - I L T-i Ik- -t-4- - - I i - - I I T ~ t----- 1 I - - - - I - ~ I - -T --=r + -r !ter--~-L---T-~ ~ l I r i I I ~ + I 1-I I T I , I I j r I ~ I j - - - - - - - - - L T -tF-4 - i------ r-- r i _ I I I I 1 1 i - - - 1 I 7 I I I I ~ i I I I T i I , ; r i i T -j _ I. I I r I I , ' - - - - ' r PAGE OF CrvSS S~c}►Ur, p~ A Zoeo SYs en F(oeh All Inlol►^And Ob►ervallon pipe 1r--Approrid Yonl Cap /~!/%A/~//7 F Minal (2d ACOV• final Grod• 20- 42' Above Plpp _ 4' Cost Iron To Final Grod• Yeni Pipe Me, M Hoy Or Syni %ok Covering win 2' Aggregate Ore' Plpe ' OIUI (Eullon ' Pipe o 0 0 Tee 6' Aoaregot0 Beneolis Pipe o perloroted Pipe belay. o Coupling Tunlnoling At Balloon 01 System SOIL FILL OISTRIBUTI01.1 PIPE APPROVED S4)JTHETIC COVER -P1ATF-R1N- OR 9" OF STRAW 2" OF AGGREGATE OR MARS" HAy F Ie~0Flz-2t~z AGGREGATE •P ~~\\\\\~i~;~ Et EV. oF EET- c. DIS-rRIF3'JTIO J PIPE TV BE AT LEASTC-20 INCHES BELOW ORIGIIJAL GRADE AWU AT LEAST LO 1►JCHES BUT 1,10 MORE. THA)J 42 IAICNES BELOW FINAL GRADE MAXIMUM MTH OF FXCAVAT100 FROM OKIGWAL 61 Ao~ WILL BE IAICHES MINIMUM OEP" OF EACA%/AT10h1 H\Oh. 0,16►NAL GRgof- WILL 6E: _ INCHES SIGIJEO: LICEUSE IJUMBEIi: DATE: