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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP
4
SECTION 32 T .7 N-R l7 W
k ADDRESS
ST. CROIX COUNT, WISCONSIN
SUBDIVISION-_,4g& frf-~r LOT 3 LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~ G~artou
fr .t~c~• ~Y 7 36
17
X
sr~
INDICATE NORTH A OW
BENCM(ARK:Elevation and description: m
Alternate benchmark_
SEPTIC TANK:Manufacturer:_ tVre,S Liquid Cap. D6
Rings used: Y' Manhole cover elev:Io y.G Final grade elev: lpS_ d
Tank inlet elev.: ~;8.g _Tank outlet elev.: rf'1,
No. of feet from nearest road:Front , Side , Rear ✓ Ft. 7 20D'
From nearest prop. line:Front , Side, Rear Ft.
No. of feet from: Well ,foB - ~h Building: 75-
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer:- Liquid Capacity:
Pump Model: Pump Pump Size
Elevation of inlet: k elevation
Pump on elev.: Pallons/cycle:
Alarm: Man.: Location
Distance from nearesSideRear_Ft.
Di stance from: Well ing
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: /i Length { S Number of Lines:_2`Area Built
Exist. Grade Elev. /04p Proposed Final Grade Elev. . _
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side2 S? Rear Ft.
No. feet from well:_1y~No. feet from building /43
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: ?/;z PLUMBER ON JOB:
LICENSE NUMBER: 3 AA?
6/90:cj
i
4 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
M DISON WI 53707 State Plan I.D. Number:
NE, SW-',;, Sec . 32 , T30-R19 C NVENTIONAL ❑ ALTERATIVE (If assigned)
964 olden Ta ❑ In-Ground Pressure ❑ Mound
NAME OF PERM IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
.Te-r r nda Jc)hnq Ti ~ 863 Strawherry Dr Hiidson , WT C119r)
BENCH MA14 (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. LEV.: CST REF. PT. ELEV . a
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
David Fogprty 11.9 A C) qt- - r-ral-x 12 A7 51
SEPTIC TANK/HOLDING TAN ,
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELE ..I ANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
~
I / / PROVIDED: PROVIDED: C7, C.
C_t x U 1, 9C4.S7 -54/ YES ❑ NO ❑ YES NO
BEDDING: r DIA.: VEMfi MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T FRESH
G • p ALARM: FEET FROM LINE: I AIR IN T•
❑ YES NO CG ❑ YES ❑ NO [NEAREST /7S
DOSING CHAMBER:
MANUFACTURER: DEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: UMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN F LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled re, construction shall cease until MAIN
the soil is dry enough to continu .
CONVENTIONAL SYSTE : LR t/, -
BED/TRENCH WIDTH: LENGM: NIO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT
DIMENSIONS
)C /
GRAVEL DEPTH FILL DEPTH DISTR. P PE DISTR. PIPE DISTR. PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET ELEV. END: II PIPES: LINE:
Pvc~ FEET / , AIR INLET:
cS 8 S. (fc a a -3 NEAREST D
MOUND SYSTEM: / 1"6-5`
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 COVE PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
EPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DE OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: AVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER11
:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: N DISTR. PIPE DISTRIB E MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: ER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO COV ❑ YES ❑ NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO / NEAREST
X N ~7 e__~r Kam..-,r
ry t_ .
.
GD~
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- 99 ..3
Sketch System on in county file for audit.
Reverse Side. SIGNATU E: TITLE: f
SBD-6710 (R. 06/88) 73!; !~g ~0 = ~
DILHR SANITARY PERMIT APPLICATION
COON
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1-:2 f-763
8% x 11 inches in size. ❑ Check If revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Jerry & Linda Jokusen NE % SW S 32 T 30 , N, R 19 E (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
863 Strawberry Drive 3 n/a
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR 68MI010SE11-
Hudsoa WI 54016 1(3867*7 Rollins Hills
II. TYPE OF BUILDING: (Check one) 11 State Owned ❑ VILLAGE ' NEAREST ROAD
3 Jose k Rolling Hills Dr ve
❑ Public 01 or2Fam.Dwelling-~#ofbedrooms3 AL QwN OF: . ELTAXNUMBER(S) Q30- / QS_ Q
III. BUILDING USE: (If building type is public, check all that apply) ~
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 ❑ SpecifyType 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
450 636 636 70 3 94.75 Feet 99.0 Feet
VII. TANK CAPACITY Site
in alIons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 000 X 1 000 1 Weeks Concrete 171 i 11 -M
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsits sewage system shown on the attached plans.
Plumber's Name (Print): P ber's Signet mps PRSW No.: Business Phone Number:
David B. Fogerty e r3289 749 3656
- t 2 1
Plumber's Address (Street, City, State, Zip Code):
Faiterty Hats. Rd. Roberta WI 54023
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin Agent Sign lure (No S ps
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination ~7
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
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 Sar,itary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior,tq installatiPil .
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. , awY3;,
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Bupia s Djyision1608-266-3815.
To be complete ar q accurate thi§,?an(Eary.ppfmit 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.
Vill. 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'/z 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 fhe' county; E) soiFtest data on a 115'foLm; and F) all siting information. 4' `
- - - - - - - - - -
GROUNDWATER SURCHARGE r
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The rnonies collected through tha, e•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 lot tesale by
ownet/eonttactot,(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 recording.
Owner of property
LocdtIon of property EE-1/4SW -/4,, Section 32
Township _St. Joseph
Nailing address
Address of site Lot 3 R
Subdivision name
Lot number 3
Previous owner of property J 4 L Land Developers, Inc.
Total also of parcel
Date parcel was created ynknewn jjr„p16Ah13C jn &Arly RnIn
Ate 611 cornets and lot lines Identifiable? =_Yes o
is this property being developed for resale (spec house)? as 0
volume 8 - and Page Number 442 as recorded with the Register of Deeds.
INCLUDE VITH THIS APPLICATION THE FOLLOVINCt
A VARRANTY DENO which Includes a DOCUMENT NUMBER, VOLUMN AND PACs NUMBER, and
the SEAL OF THN RNOISTER OF DEEDS. In addition, a testified survey, if
avallable, would be helpful so as to avoid delays of the reviewing process. If
the deed descclptlon references to a Cet:tifled Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(Vs) certify that all statements on this form are true to the best of my (out)
knowledge= that I (we) am (ate) the owner(s) of the property described In
this Infotmatlon form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. 46n6R4 1 and that I (Ye)
Presently own the proposed alto for the sewage disposal system (or I (we) have
obtained an easement, to tun with the above 'described property, for the
construction of said system, and the same has bee) recorded in the office
of the Count egl r of Oeeds, as Document No.
signature of Owner Signature of Co-owner (If Applicable)
g' 2-3 - 9,0
Date of signature Date of Signature
DOCUMENT NO. _ WARRANTY DEED-By Corporation
STATE OF WISCONSIN-FORM 10
Pa`r THIS SPACE MUM FOP RECORDING DATA 4 A'
460684
~j 6~j REGISTER'S OFFICE
THIS INDENTUR$, Made by J & L Land 'Developers, ST. CROIX CO., WI
Inc., a Wisconsin :oorporatio.n Recd for Record
a Corporation J U L 2 01990
duly organized and existing under and by virtue of the laws of the State of Wisconsin, grantor, Q~ 4.15 p. tM
of St. Croix County, Wisconsin, hereby conveys and warrants to
Gerald A. Johnson and Linda D. Johnson, husband c.vw+,.4A
and wife as marital survivorship property RepisterofDo@&
grantees-, of St. Croi x County Wisconsin, for the sum of
Twenty thousand, eight .hundred fifty o0/10-0 RETURN TO Gwin & Gwin
dollars 430 Second St.
the following tract of land in St Croix County, State of Wisconsin: Hudson, WI 5401
y
A parcel of land located in the NE]# of the SW's of Section 32,
_ To Up_ 3 0. North, Range-_19.. Site st-r tb_e
St. Croix :..County, Wisconsin, described as.follows: ti
Lot 3 of the Certified Survey Map-filed June 25, 1990*in Vo.l: 8,
at Page 2233, as Document No. 459864 in-the Register'of Deeds
Office for St. Croix County, Wisconsin.
FEE
r
i
In Witness Whereof, the said grantor has caused these presents to be signed by Gerald A. Johnson
x its President, and countersigned by Linda D. Johnson its Secretary, at Hudson - ,
Wisconsin, a W-4wecvperaie-seal-le-,fiber ea rte. armied, this-I& e~day of July , A. D., 19 90
No corporate seal
SIGNED AND SEALED IN PRESENCE OF
J & L Land Developers, Inc.
Corporate Name
li
President
Gerald A- (Johnson
COUNTERSIGNED:
ICY
,l
Linda D. Johnson
STATE OF WISCONSIN,
St. Croix Coil gg'
Personally came before me, thisday of JulY , A. D., 19 90 Gerald A. Johnson 4
President, and Linda D. Johnson , Secretary of the above
named Corporation, to me known to be the persons who executed the foregoing instrument, and to me known to be such President
and Secretary of said Corporation, and acknowledged that they executed the foregoing instrument as such officers as the
deed of said Corporation, by its authority.}
Hugh F. Gwin
s,,'-',S'.
This instrument drafted by Notary Public St. Croix County, Wis.
Att~yt Hu .h H. Gwin Gwin & ? A J My Commission (i) (Is) permanent
n~
ra
(Section ".61 (t) of the Wisconsin Statutes provides t .6 recorded shall hove plainly printed or typewriVen thereon the
names of the Grantors, grantees, witnesses and notary). VAS,
WARRANTY DEED-STATE OF WISCONSIN, FORM NO. lOr~~„y HWerCarprb
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A
CERTIFIED SURVEY MAP
Located in part of the NE4 of the SA of section 32,
T30N, R19W, Town of St. Joseph, St. Croix County, Wisconsin.
~I
LINE DATA TABLE
LEGEND Line Bearing Length
2 - 3 S70011'1811E 50.00'
St. Croix County Section Corner Monument 6 - 7 S7001111811E 50.00'
5 - 1 N49°52' 5411E 36.30'
0 111 Iron pipe found 4 - 8 S220341541IW 33.01'
~t-r--:- existing fence
CURVE DATA Central Chord Chord Arc
Curve # Radius Angle Bearing Length Length Tangent Bearing Tangent Bearing
1 - 2 200.00' 3022'05" S68030115.511E 11.76' 11.761 S66049'131'E 570011118"E
3 - 4 200.00' 200411211 S69009'12"E 7.23' 7.23' S7001111811E S68007'0611E
5 - 6 233.001 7022'56" S66029'5011E 30.001 30.02' 56204812211E S7001111811E
7 - 8 167.00' 105515411 S6901312111E 5.63' 5.63' S7001111811E S68015'24"E
\ \
Unplatted Lands
Unplatted Lands
West } Corner \ \O ~ ~
Section 32 2 3 \
~5 4 \
~60-, \
Common
'R'b Drive
rh J I
cF^ K. i v I ~ cp
Est s , i".~~'•4 W I ,L~h /
w I
ft i
z?
ALLrR1 o ; cam/ y
o I LOT 3
~ ML 7. 0/ N L N
4j M
181,694 sq. ft.)
o 1'YE 4.17 acres ) INCLUDING R/W 3 0 1 o
% CD
° 179,106 sq. ft.) o
o° d o W
N o 3`~Aitr. >>'A o In q-
0 4.11 acres ) EXCLUDING R/W o
c 1562.731 0° ° C>
z Cn W .n
L W
O L O
41 -W
CD J` S8905113611W 430.00'
c+ v
O W
o° N8905113611E ]
C South line of the NJ of the SWJ C- W
N
co +C N
N W • .I N
a unplatted lands owned by others m
m
M OWNER SCALE IN FEET 111= 150'
JE L Land Developer's Inc. 1I 0 50 100 150
863 Strawberry Drive
Hudson, WI 54016
Southwest Corner
Section 32 This instrument drafted by Brett Budrow Proj. # 77-84-190
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Jerry & Linda Johnson
ROUTE/BOX NUMBER 863 Strawberry Drive FIRE NO. n/a
CITY/STATE-Hudson, WI 54016 ZIP
30
PROPERTY LOCATION: NE 1/4 SW 1/4, Section 32 , T W N, R 19 W,
Town of St. Joseph , St. Croix County,
Subdivision Rolling Hills , Lot No. 3
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
V 61/
DATE
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
1C
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INRUS'I RY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN FrELATIONS
(1LHR 83.09(1) & Chapter 145)
L ~TIO SECTION: TOWNSHIP/MUNICIPALITY: OT NO.: BLK. O.: SU DIVISION NAME:
COUNTY: OWNER'S 8 YER'S NAME: IMAIL
✓T G ADDRESS:
Croix JC ' c o
USE DATES O ERV TIONS MA 6E
NO. BEDRMS.: COMMERCI L DESCR PTIO R C O ESTS:
ew ❑Replace O 1 V
Residence ?
AMA
RATING: S= Site suitable for system U_= Site unsuitable for system
S
(HIV ETI~~ , Ma ~'A IN 15-M EA E. SQ S IOUL OLD F ING TANK: RECOMME7LNQED SYSTEM- Iopt~n
J([~j~~ S '•~~C/~J U C/A711Y.~+7ne_'"~ ! ja-e.(/
:
If Percolation Tests are NOT DESIGN RATE required i,,4 If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: < 3 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHJfV, ELEVATION OBSERVED ES HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
6 ~3 • \ g3 " , 13 Lam/ / 2 S xr. ZS S, o'
r
9,. yi't►.~s
33 '/sue, .sT . 9.2 ' A+ t 3
B-3 .17 ~ 7,2 ;r > 01./7" . Sg'B~ u• 9.L''s os/~ 33 t3ss IsQ'js- . 3 3 S 09
Q w qr SJ, o ,d.► ~'!yr
p, f: 7 33 /j//~ 4 33'
2.51
B- 7" 9/.
U' , ` 7 Ef~/ ~drtJ, SS 7 /1., s ~j w s
B-s f
B-
PERCOLATION TESTS
TEST DEPT ATER IN HOLE TEST TIME DROPIN WATER LEVEL-INCHES RATE MINUTES
NUMBER FTE E LING INTERVAL-MIN. p PE PERIOD 3 PER INCH
P_ S, g3 2-
P 5 2 3
P_ .O' < 3
P-
D_ I _
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
E
E; 76
3 '
3 6p \ ! ivo, 4F Colr~w:S !~7` 3
tl
i 6
r
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7
1
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME TESTS WE CO LETED ON:
ADDRESS. CER IFIC I N NUMBER: PHONE NUMBER (optional):
7 Soy ~s~. cl<< SY~I.~ f~ p'r-
CST GN
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil, Tester.
DILHR-SBD-6395 (R, 10183) - OVER -
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