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HomeMy WebLinkAbout038-1079-80-000 vMi O o~ 0o a+ o w g ~ I b o I O N I a o I m I I ~ I I ~ I Co (D I 0 z 0 I c c L m E I c LL O I I 3 a co 3 v ~ I Z Li ao w E ~ O z z I m m a m w M O i H U) I C i O c C7 O Z ~ c ~ I 0 I i 2 U) Y, C z C E ~~V N N 3 c a CD I 7 (_D y o a N L Q O z m z 6 Z I N c p y c I N I _ ~ N m i d- d C ~y a a o c o 0 f C, C. ~i o I CN .n m o N N O a IL ~ w Q p A N to fn E v O O W„J Z co F- FL co N N O O a a a z •N ~ CL N 0 o fn J V p rn rn Z Q I ITV U) N N 0 N i L t17 to w 0 E ~ I O O 'O co c a o ~ N N (0 0 'p d Q ~ fn m t~ N to O ~ ! H C O 9 co FO- Y L) O O W X 0 0 C? o o i oo m a Cl `a cq -r- E o o c j 0) 0 d CD F- H C N ~ V) 0Mi m o E E R u o in 2 o z :9 i9 m V CL 'c c `iv 10 CL 0 U) 0 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER '5OWNSHIP / L SEC. 3;j~Z_N-R ff W ADDRESS ST. CROIX COUNTY, WISCONSIN e~cY Ix? SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 111HR 83 SHOW EVERYTHING WITHIN 100 FEET OF YSTE i 4D~ ~ s 0 y ..w INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used c ,g~i5f G~ 7 Elevation of vertical reference point: /1~'& Proposed slope at site: SEPTIC TANK: Manufacturer: zo. GG /5 Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation:- S Tank Outlet Elevation: Number of feet from nearest Road.: Front, Side0 Rear, O zz' feet -From nearest-propertyline Front 10 Side 10 Rear,0 'L"L7Of feet Number of feet from: well ,~~1// Yvo building: O o,L (Include this information of the above plot plan)( 2 reference dimensions to septic tank) " _ SFF _BF.VF.RSF. STnF. • J PUMP CHAMBER Manufacturer: 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, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: V Trench: Width:_ Length: / Number of Lines:_ Area Built Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 It ~/O d Number of feet from well,: 411-/0T Number of feet from building: (Include distances on plot plan).` SEEPAGE PIT y'~ 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, OFt. Number of feet from mell: Number feet from building: of Number of feet from nearest ` road:` r Alarm Manufacturer: Inspector: Dated: !___r_/~ / Plumber on job: w License Number: 3 g 3/84:mj 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 ~nEAplsvl 57o7 State Plan I.D. Number: 4 f 4 f ec • 19 , T31-R18 (If assigned) Town of Star Prair ❑x CONVENTIONAL ❑ ALTERATIVE 90th S ~1 Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Keith He erness Somerset WI 54025 (,1-:21 , BENCH MARK (Perm n nt reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF'. PT. EL V.: CST REF. PT. ELEV.:' Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: ,Byron Bird Jr. 3318 St. Croix SEPTIC TANK/HOLDING TANK: l ' CU "off Malini(t .G3 MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET V.: WARNING LABEL LOCKING COVER _ PROVIDED: PROVIDED: 1061 ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VE#T DIA.: VF"TWATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WEL : BUILDING: VENT TO FRESH e , d. ALARM: FEET FROM LINE: / / AIR INLET: Ile E] YES NO ❑ YES 0 NEAREST 0 VI 11 1 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ 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 into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: 9, S( BED/TRENCH WIDTH: LE NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID / / TRENCHES: I MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE M TERIAL: NO ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH s f BELOW PIP : ABOVE COVER: ELEV. INLET: ELEV. ENO: f t- rC pg PIPES: FEET FROM LINE: , I / AIR VLET: Co - QS 06"15 3 a NEAREST ►1 MOUND SYSTEM: CS- 0,.(, Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: DEPTHS ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST rrlm _e. 6" Sketch System on etoin in county file for audit. Reverse Side. SIGNA URE: TITLE: SBD-6710 (R. 06/88) / rye Sc DiLHR SANITARY PERMIT APPLICATION .76 In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~.~"..,..e :5 o w STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than l 3s5 42~ 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 OWNE PROPERTY LOCATION N, R E (or~ e 5jF 1/a S /I T TBLOCK# PROPERTY OWNER'S MAILING ADDRESS LOT # p rr, <h S-e 74- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1,.:-S 7--1 n II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAyD n /ar ~re /r'i~ O fj SJ~ ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms,- PARCEL TAX NUMBER(S) 03~ 607 _ _O III. BUILDING USE: (If building type is public, check all that apply) 2 O d 1 ❑ Apt/Condo v G 444//J 20 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. WNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 NeepageTrench eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 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 c-- S ✓ Feet woe Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank G►~29 Lift Pump Tank/Si hon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' nature: (No Stamps) MP/MPRSW No.:cJ~/ Business Phone Number: l r0 /1 ~ i~ ~ 3r 4 /rJ rZ~ '9 =~la~l~ Plumber's Address (Street, City, State, Zip Code): IX. CO TY/DEPARTME USE ONLY I_Lss ❑ Disapproved I Z Sanitary Permit Fee (Includes Groundwater Date Issued uing Agent Signature (No Stamps) Approved ❑ Owner Given Initial JZ Surcharge Pee) Adverse Determination 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 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. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of-standards. SBD-6398 (R.11/88) APPLICATION FOR SANITARY VZRMIT 8TC-100 This application form Is to be completed In full and signed by the ovnec(s) of the property being developed. Any inadequacies trill only tesult in delays of the petmit Issuance. -Should this development be intended got tesale by owner/contractor,(spee house), then a second forty, should be retained and completed when the property Is sold and submitted to this office with the appcopzlate deed recording. Owner of property ei~ ~~f;i1 CC ernf~ ~,y Location of property /4 ME, /4, section •_1 T P-R1,k.Y Township Malling address c) R'ox f 6. • Address of site ~ 910 P Ilr 1 L01 SWba C.~~m, V~I.~ P~ ►sa~ . sabdivlslon nasie, Lot number 4- Previous owner of property Total also of parcel I D W o (e- C Data parcel was created Are all cornets and lot lines Identifiable? ~_Yes __J10 Is this property being developed tot resale tapec house)?as ~I0 Voluaw nd Page Number y recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION TIM FOLLOWINGI A WARRANTY Drip which Includes a DOCUMRNT NUMBRR, VOLUN= AND PAOR NUNBIM* and the 8f AL OF THS REGISTER OF DEEDB. In addltlon, • cartlfled survey, It available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a Certlfled Survey Map, the Certified Survey Map shall also be requited. PROPERTY OWNER CERTIFICATION I(We1 certify that all statements on this form are true to the best of my (ouc) Rnowledgel that I (we) am (ate) the owner(s) of the property described in this lntocmatlon form, by virtue of a warran1162 ad recorded In the office of the County Register of Deeds as Document No. !2!VR I and that I (We) presently own the proposed site lot the savage disposal system (or 1 (vel have obtained an easement, to run with the above described property, tot the consttuctlon of sold system, and the same has been duly recorded in the otfiee of the Count Reglat of Deeds# a Document NO' Slgnatuce o own signature of OkB&t (If Applicable) s'-a5 -~v 5 ~S-~jD ate of signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 458943 REGISTER'S OFFICE Everett F. Cloutier and Adeline Cloutier, ST. CROIX CO., WI husband and Wife Recd for Record at MAY 2 51990 conveys and warrants to Keith A. Heg ernes and Helen 2:00 P M Heg,q:ernes, husband and wife, as marital property with rights of survivorship► Regiiier~~# 'deeds i RETURN TO the following described real estate in St. Croix County, I State of Wisconsin: 2 Tax Parcel No: Lot Three (3) of Certified Survey Map, filed May 22, 1985 in Volume "6" of Certified Survey Maps, page 1526, as DocumentNo. 402164, EXCEPTING therefrom Lot One (1) of Certified Survey Map, filed March 9, 1987 in Volume "6" of Certified Survey Maps, page 1786, as Document No. 423126, Located in the Southeast Quarter of the Northeast Quarter (SEA of NE'-) of Section Nineteen (19), Township Thirty-one (31) North, of Range Eighteen (18) West. b0f._.- This is not homestead property. (is) (is not) Exception to Warranties: Dated this day of ~Z2211 -,e-4 119 (SEAL) (SEAL) (SEAL) /Gtc' ~O / / P V (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. authenticated this day of , 19 Personally came before me this 25th day of May , 192_ the above named Adeline Cloutier and Everett F. Cloutier TITLE: MEMBER STATE BAR OF WISCONSIN (if not, to me known to be the person s who executed the authorized by § 706.06, Wis. Stats.) foregoing in~tFU~~t m~ acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY v6 9/x- 4L 1(, ~Notary- ' ' fit- c4ix County, Wis. Signatures may be authenticated or acknowledged. Both My COnmissiorr-is~Sper-Tanent. (If not, state expiration are not necessary.)~~ ~7- 9 ) date: 1 t Names of persons signing in any capacity should be typed or printed below their signatures. r,SB2 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 Form No 2 - 1982 N SEPTIC TANK MAINTENANCE AGREEMENT ~ St. Croix Count WNER BUYER -e af~,-Qrr)_.e_3 w 2:C~(n g 0 ROUTE/BOX NUMBER Fire Number Coc~ d _~L/ O o1Ca cwt CITY/STATE ZIP M 5 section, T_N, R_W, L PROPERTY LOCATION Town of-'::--"(- I Y'iZ St. Croix County, Subdivision C 'Z~ d fy),_jaL(6Lot number__. Improper use and maintenance of your stic 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 'septic tank um er. What you put into the system can affect the function ot 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 systems 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 the standards set forth, herein, as.set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed •d and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNS DATE- - In St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. ~ y I, DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 769 N WI 37 HUMAN RELATIONS 07 JLHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS /MUNICIPALITY: OT NO. rLW).: SUBDIVISION NAME: IY- V4 / COUNTY: MAILfIN A 666 SS: US DATES OBSERVATIONS MADE6/62 -7/7C7- NO. BEDRMS : COMM R AL DESCRIPTION : Residence - New ❑Replace RATING: S- Site suitable for system U- Site unsuitable for system ~s 3D ONVENTIONAL: MOUND: ESs IN-GROUN ESSURE: S STEM•IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ou ®s [:]U rAS ou a s IZU ros au 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 P H T R Ut DWATER•INCH S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION BS V D TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) o ~ .Syr -g~ /3n B- zoz C/ :i 11A -62-0 '007 5,9 B- 1.4 / B 7 B- S ~it'v /a /b 5 /o -.Io ~Sy► o?D ~G~ •z,,'7~•'' 6- PERCOLATION TESTS If 00, t TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAT MINUTES NUMBER . AFTERSWELLING INTERVAL-MIN. I PER INCH P- A P- d C r- L P- G 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 ill borings and the direction and percent of land slope. SYSTEM ELEVATION. s. ' i N 14 1 0 b+ i r I , _ _ . # i. 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: Z/ -/j - effil ADDRESS: -tf C RTIFICATION NUMBER: PHONE NUMBER optional): fr-z ~zr 00 7 71 CST SIGNATUREt' DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. J PLOT PLAN _ PROJECT y7 ADDRESS 1 /4 /1-1/4/S/ /Ty N/R A- W TOWN ~ar COUNTY MPRS Byron Bird r. 3318 DATE _ - a BEDROOM CLASS PERC_~ CONVENTIONAL IN-GROUND ESSURE CONVENTI NAL LIFT- MOUND_ HOLDING TANK SEPTIC TANK SIZE / LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA a PERC RATE -5; BED SIZE ► Benchmark V.R.P. Assume Elevation 100' Location of Benchmark s~ zoc- * H.R..P. --57- M Borehole Q Well Scale = Feet 0 Perc Hole System Elevation 10q- 5- Vent 12" Grade TYPAR COVERING 2" 12 3' 4 6' ® 3' " Sewer Rock 6 12' a dal°~ / ~ 1 ~o 1 yV / Qn' ` N ado 0 JU INDEP E , ~TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 79069 HUMAN RELATIONS LHR 83.0911) & Chapter 145) LOCATION: CTI H/ I)T- TOWNS /MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: CV_ I WEE 1 / - ~5f - - 31 COUNTY: MAILING ADDRESS: 41e 2~`/IB ~OL Gc / moo SS/O US DATES OBSERVATIONS MADEGiIa -7VC,7- NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRTPTMs: PERCOLATION TS: Residence 'gNew ❑ Replace RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMEN r lZu ®S DED SYSTEM: (optional) ❑U S DU ~S DU ❑ S ❑ S DU Vii. If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.0915)(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 EST.Hl HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13- B- B-3 1~~o ,&.7s~ _/~q Ale B- t4 B- Alp PERCOLATION TESTS L TEST DEPTH . WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES f NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- d 2 G P- ® G 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. 'c eP, I t e i [ E r ~ t O l ; - h [ I b E 1 E i F f I t [ t I ! ° t I L 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 : 1 TESTS WERE COMPLETED ON: A/ell ADDRESS: C RTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNA UR Ee' DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM i 1S - 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 Soil 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 fs - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand 'c - Less Than 'I - Loam Bn - Brown 'sit - Silt 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