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HomeMy WebLinkAbout032-2005-95-000 O y m~ 'o C 3 > > 0 3 I co ~ A~ • I Z O N m o W O• s c a o 0: 3 w N ry M CD N co pm N O N w 3 3 w co ' m to N N m a Cc O O O O p N N N a 07 m p 0 Jo to to D a m m N Cn CL m _W = a Z~ N3 V Cf) CD CD a CD 0 C O p tO fD C4 O 0 0 fA Q !r oz o003 ~y~• n a CO) vi vi L m ~7 r-3 O O N 0 CD (D W Lo. -0 M CD A $ l~ O 3 C1 V 7 N Q CL w to ` Z O O D a co 0 m cn y C C N CJ ~ d Z m Cb N v n A 0 W M Cao CD I 0 .az o . C co 3 co z m A C.) I C a c I 3 m c o' o CL I ~i y I a I o I I ~ I 0 I ~ z I w N °o I a I A ti o cv CD ~0 1 69 O k" p F O m ° b 0 ti I o i y 1` l ~s ~ -5- V ~I Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT GCaz- C is~y! OWNER TOWNSHIP SEC. T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IMR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 0 Ti 7 X60 , INDICATE NORTH ARROW O a-G~ BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: /6 a Proposed slope at site: SEPTIC TANK: Manufacturer: --,ham ~s Liquid Capacity: Number of rings used: Tank manhole cover elevation: / a P?, IC Tank Inlet Elevation: A 72 Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side 0 Rear, Imo feet -From nearest-property line ' Front,0Side,0Rear,0 feet Number of feet from: well X10 wcf/ building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE. STD E PUMP CHAMBER Manufacturer: y Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: a Lengkh: y S Number of Lines: Area Built:i Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,0 pt. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Gr~ Size: Number of pits: Diameter: Liquid depth: 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? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: - 6 Plumber on job: License Number: 3/84:mj r C ~ vo oo~~~ 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 SZMA~ 4j 4,Sec. 1, T30N-R1 (It State Number: Town of Somerset CONVENTIONAL ❑ ALTERATIVE 85th St. ❑ 1-101 ingTank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIONp TEd Dave Erickson 11870 Wall St. New Richmond WI 54 17 D 3v BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ST REF. PT. ELEV.: 2.60 Name of Plumber: M - MPRSW No.: County: Sanitary Permit Number: ,Byron Bird. Jr. 3318 St. ix 128699 SEPTIC TANK/HOLDING TANK: M&I 4011 G'rvtc/~ 416/ G. Zb' MANUFACTURER: LIQUID CAPACITY: TTANK OU V.: WARNING LABEL LOCKING COVER 99. PROVIDED: PROVIDED: I ~~G✓ )5 (11IV Q U . S YES ❑ NO F] YES NO BEDDING: V~F DIA.: VC40 MATL.: HIGH WATER NUMBER O ROAD: PROPERTY WE BUILDING IV ENT T FRESH • ~•O • ALARM: FEET FROM LINE:_ i AIR INLET ❑ YES Z O NO f ❑ YES NO NEAREST y ~~D ~1TL DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID DEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS YCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFF CE BETWEEN ROM LINE: AIR INLET: PUMP ON AND OFF El YES ❑ NO NEARE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIA or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: 5 - ,92` sic t n tl. _ ~7 v3 ' BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE S ING: COVER INSIDE DIA.: # PITS: LIQUID / r TRENCHES: C.Or MATERIAL: PIT DEPTH: DIMENSIONS 10 ae- GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PI E DISTR. PIPE MATERIAL: NO. D STR. NUMBER OF PROPERTY WELL, BUILDING: VENT TO FRESH BELOW PIPS: ABOVE COVER: ELEV. INLET: ELEV. END: ~'~Fe f IDES: FEET FROM LINE: gym/ AIR INLET: NEAREST (/v 310' L2~ MOUND SYSTEM: 7.6 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 TEXTUR PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER NCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:, CENTER: EDGES: YES ❑ NO ❑ YES ❑ NO ❑ Y4 ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH B IPE: FILL DEPTH ABOVE COVE TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: R MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO COVE ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: 7NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑~YES ❑ NO ❑ YES ❑ NO NEAREST -71 C Sketch System on a in in county file for audit. Reverse Side. SIGNA RE: TITLE: SBD-6710 (R. 06/88) SANITARY PEhMIT APPLICATION COUNTY DILR In accord with ILHR 83.05, Wis. Adm. Code ~ MEMO STAT SA ITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 LIdZius 8% x 11 inches in size. c if r application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OW , PROPERTY LOCATION GcU C r 4, S TAO, N, R -jF E (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK 7'r JPJTY1 TAE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM N~ ER II. TYPE OF BOIL ING: (Check one) ❑ State owned VILLLLAGE NEAREST ROAD VZ40W OF: ❑ Public fZ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX N ER() S_ III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo (J / 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. ❑ 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 220 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 f~ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ` 3v 1 G Feet Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete strutted glass App. Septic Tank or Holdin Tank Tanks Tanks Lift Pump Tank/Si hon Chamber I I I I- IKF~Fjl F] F] Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's me (Print): Plumber' Signature: (No Stam s) MP/MPRSW No.: Business Phone Number: rph d/1 4c;( 1 ( / E 761,E Plumber's dress (Street, City, State, Zip Code): f 40 6 er fir' 0m IX. COUNTY DEPAR MENT USE ONLY ❑ Disapproved 11 Sanitary Permit Fee (Includes Groundwater Date Issued Issui Agent Signature (No Stamps) Approved ❑ Owner Given Initial /q~,- Surcharge Fee) -OA Adverse Determination / X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD46398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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 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: 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 sectio!i 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 USE:d 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 1n 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 got resale by owner/contcactot,(spec house), then a second form should be retained and completed when the ptopetty is sold and submitted to this office with the appcopciate deed cecording. Owner of property 19,4 V, ' iG/~ r c-1 Location of propacS~ Ey~,l/4 1/ir section T 3a~-R~v Township Nalilnq address Address of site Ao~ r/ar 6-lecf eze-,- Al x_ Ad /46Lg,o, Xe Jr. Subdivision name- • Lot number /I~6,Ve Previous owner of ptopetty 11 e1✓,✓e e,h,P-,- Total size of parcel ®Ag~y owe- 14e2es ,ol Data parcel was created - II S 7 Are all cornets and lot lines Identifiable? X_Yes o Is this ptopetty being developed for resale Caper house)? an /4 0 Volume 0/116 and Page Number `R45 as recorded with the Register of Deeds. --•-••-------r-••--~•~-•-•..•~--••--•-------------- IMCLUDS WITH THIS APPLICATION TIM FOLLOVINCI A WARRANTY DIED which Includes a DOCUMENT NUMBRR, VOLUMit AND PAOt MUNatR, and the sRAL OF THE REMOTER OF DBEDE. In addition, a cettifled survey, If available, would be helpful so as to avoid delays of the tevlawlnq process. It the deed desctlptlon taterenees to a Castlfled Survey Nap, the Certified Survey Map shall also be tequlred. ---------------------------------------------------------7-----------•--------- PROPERTY OWNER CERTIFICATION ((wel cettlty that all statements on this form are true to the best of my (our) Rnovledgel that I (we) am (ate) the owner(s) of the ptopetty deaetlbed In this Intotmatlon totm, by virtue of a wactanty deed recorded In the Office of the County Reglstet of Deeds as Document No. 4'S11790 2 1 and that I (we) ptesently own the ptoposed site for the savage disposal system (oc I (we) have obtained an easement, to tun with the above desetlbed ptopetty, Eot the construction of said system, and the same has been d l recorded in the office of the County Register of Deeds, as Document No. m 1, ua~ Tgnatuce of Owner 8 gnatu of co-owner (t Applicable) Dstavol to of signature 2" air, N ~ low arena rnora►- NO. 0~~ ~I slum* K!1l1!!lillTih..tl1~' ••IIiR1fd .1'l~ t11..~lati a .Grubier , husband ..•ic~d..>rti~l._d..MAiareal...l.._Acu~iur Ju,1 45 - 1 •M aad....Owttid L... Lrrl~alcsom.and_9!>~rrac..L~..F.al~udcsr.•-- Q li~++M4+~ 000111114114111010015, ......lM .jail (ranter, fe! a valslabla - a WitneNWkh, ' _ ___KAbcfnuttlh,.lNEtd.Alta..Gra~bar.-~nd..Kialaasl..IIruber.___-_ armait TO aswa to armose the tepewlnt daai:rlbad awl artate ii SL .•-.Croix•-•----- ` Cnailp. s of wh unwi.: , All that part of the 8% of the S% of the g SW% of Section 1 dying Northerly of the Tax Parcel NO: Railroad right-of-way and all that part of the W%. of the NW% of Section ie lying Northerly of the Railroad right-of-way, ■ll in Township 3014, Range ism. I € S 1 j This In ..nat....... homestead property. (in no!) To`stine W11:111 all mW Singular the haoditamdOb and appurtenances thereunto belonging: And...... Kitn).ath..and..Hltw-..Gr_t.Ibar_..RnA.-Mochae.l. - Gruber.......... except i i Wsrraets that the title is goad, indefeeaible in fee aiimpk and free and clear of encumbrances easements, restrictions and rights-of-way of record, if any. (1 - and will warrant sad defend the same 11.89,,. , Dated tbfs ..._••---•-------•-..~-h................. day of . . . Ju ly. . - _ si _ (SEAL) ~'P""~'r Q~ ti.~.,.-• Kannsth S. Gruber Rite Marie Gruber .(SEAL). --•--•(SSAL) i ? f . Michael Gruber _ - - i I' AUTZENTICATION ACKNOWL'DOMENT glgoaft"(j) -Kenneth S STATE OF WISCONSIN i ~tr4l~14C..- Rto Maria Gruber, Michael J. 115. ~rnber .County. x y entrant/ipi this lv!~day offf."._...+jw.y............ 19.919• Personally came before me this day of 1 the above naiad Kristine Ogland Lundeen . TITLE: MEMBER STATE BAR OF WISCONSIN ` (If not: • - - • authorised by ii 708.06 Win. Ststs.) to me known to he the person who executed the foregminq instrument and acknowledge the same •i. THIS INSTRUMENT WAS DRAFTED BY Kristine Ogland Lundeen Attornsy et Lew _ Nota-,. 1,1111lic -_Coafttx. wia• ' Commission Signatures may be authenticated or acknowledued. Both Commission is permanent. (If not. state experation ( are not necessary.) date: I'll 11 gb21aa at Ieeaaaa alaaisa in any capacity ebould be typed or printed hO- their aiQn. t+n t~ STATE SAN OF WISCONSIN MauoMa 'v6I* ~ ':a , . R~ USED snitss Na.. I - Ifat in SEPTIC TANK MAINTENANCE AGREEMENT w3 St. Croix County / ~J L . F/i /c/~CSo 1✓ She eA y' o OWNER/ BUYER_ rt ROUTE/BOX NUMBER Fire Number" r7© g 8 V 0 CITY/STATE ZIP S Yak ' r PROPERTY LOCATION' k,j , Section T_Zo N, RAW, Town of So lhe~e 5g-Z St. Croix County, SubdivisionLot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover 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 aMelc-t t-Tie- .unct on or t e 'septic tank as a treat- ment-stage in the waste disposal system. St. Croix Countyy residents may be eligible to recieve 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 .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 0 to maintain the private sewage disposal system in accordance with 9 the standards set forth, herein, as set by the Wisconsin Depart- W 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. SIGNED DATE :r-~.,✓e ~y g..yo 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 c P.O. BOX 7969 LABOR AND RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 0 HR 83.0911) & Chapter 145) 140 SECTION: WN UNICIPALITY: OT NO.:BLK NO.: SUBDIVISION NAME: N/R1 E (o _ MAILING ADDRESS: M USE DATES OBSERVATIONS MDE a ~j NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: PERCOLATION TESTS: PResidence 31 New ❑ Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) E] S DU gS ❑U9S ❑U ❑ S U ❑ S ZU If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BA K.) 13- B_ " B_ PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD T P RIOD P R PER INCH P- / P- X7 - D -•.2 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. SYSTEM ELEVATION. f E ( oea r i z 1 ~ _ ~ r,, r" _ 4 F tN r.-i e.~ C I ~ 1 t -'~~--i `'ter ~`1` G~~ ~~cs - _ • ll P ~ E E 1 4E 4~ F F I 3 I I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: 011 )zoo"" rye! z - - - ~42 ADDRESS: CERTIFICATION NUMBER: 11PHONE NUMBER (optional): CST SIGNAT azy 3- DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - 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; 6. 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 scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soli Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well Is - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand - Less Than '1 - Loam Bn - Brown 'sil - Sift Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical 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. PLOT PLAN ` PROJECT. (I/~vc 2~tc1(3v - 'ADDRESS 1-6,20 s ~jC1/4 ,ow 1/4/S /T3o N/R W TOWN COUNTY)'.Gf rx 1 M RS Byron Bird Jr. 3318 IJA E - - BEDROOM 07 CLASS PERC_,/ CONV NTIONALA IN-GROI IKFF9 CONVENTI NAL LIFT_ MOUND_ HOLDIN TANK SEPTIC TANK SIZE ~a iFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA e5,P-~~ PERC RATE BED SIZE _li•XS-J.~ 111ti, Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H. R. P. SE CI Borehole Q Well Scale = Feet 0 Perc Hole System Elevation 7 Uent 12' Grade ~i TYPAR COVERING 2" 12. 3' 4 6' O 3' 1 6 „ Sewer Rock 1.2' C2~ /W7 (d ~ hey ~ of ti A • r - 0