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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER La vo el tl-- TOWNSHIP
SECTION _,Z T_ZI-N-R /1' W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE -
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
z'
1al
0 17
~y .
t sa
S~
r~ a~
INDICATE NORTH ARROW
t
BENCHMARK:Elevation and description: 2
Alternate benchmark
SEPTIC TANK:Manufacturer: ly.e e ~5 Liquid Cap.
Rings used:&0 Manhole cover elev:~Final grade elev: 7•
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front , Side,, Rear--Ft. -;70
From nearest prop. line:Front , Side, Rear Ft.
No. of feet from: Well Building: 36
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
s
PUMP CRAMER
Manufacturer: Liquid Capacity:
Pump Model:_Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: 'Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front-, Side-, Rear_Ft._
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: x Trench: Seepage Pit:
Width:=Length ~ Number of Lines:-Cl-_Area Built
o~
Exist. Grade Elev. ~5- 2-proposed Final Grade Elev.
Fill depth to top of pipe:_ ,20 a
I
No. feet from nearest prop. line:Front , Side,, Rear Ft. g;~O
No. feat from well: _No. feet from building 7y
0 ING 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: Wellbuilding , nearest road
Alarm Manufacturer:
i
INSPECTOR:
DATE:-,- - 72 PLUMBER ON JOB :
LICENSE NUMBER: ~l
6/90:cj
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
4 ~ , S(if te sfined) Number:
NAV, ,Sec27 T31-R18
Town of Star Prairi CONVENTIONAL ❑ ALTERATIVE
114th St. It] Hol XingTank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: =Rt. ESS OF PERMIT HOLDER: INSPECTION DATE:
Harold C. Olson 2 Box 253, New Richmond, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFEREN FROM PLAN: REF. PT. EL V.: CST REF. PT. EL ,
- fpyn ~ ~.v o.~
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Byron Bird Jr. 3318 St Croix 128719
t SEPTIC TANK/ : 3•~. O~ -
WARNING LABEL LOCKING COVER
t~ MANUFACTURER: LIQUID CAPACITY: TANK INLET TANK OUTLE TtrEg_
/ PROVIDED: PROVIDED: 6,6 °
az ql~ S. c6 P7 YES ❑ NO ❑ YES NO
BEDDING: 44E"T'DIA.: VERlrMATL.: HIGH WATER UMBER OF ROAD: PROPERTY( I WELL: BUILDING: VENT T RESH
C.p, ,1 e ALARM: FEET FROM LINE: / / / AIR INLET:
WN O ~ NEAREST ~ 1' 9
3
❑ YES NO ❑ YES
DOSING /CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: JPUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM 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 into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: LIQUID
TRENCHES: ♦ MATERIAL: DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DIST PIPE MATERIAL-.._ NO DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT FRESH
E FEET FROM LINE: AIR INLET:
BELOW PIPES: ABOV~ COVEFL ELEV. INLET- ELEV. ND:.- r; y5 tPIP
y - 6 T'• &'-sfa~, aq_Lf NEAREST---* .79
MOUND SYSTEM s- (4,(,7)'
'
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 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 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:
L.) T / ❑ YES ❑ NO ❑ YES ❑ NO NEAREST 1111,
tA d Az,
e4)
a/1F c~,ri d
fib ~~'.~c~-t . C~,~u.c~-~~.~-r~ ~ .-c-~•~-i a.%~c~ y~°~~~,
Sketch System on etain in county file for audit.
Reverse Side. SIGN RE: TITLE
SBD-6710 (R. 06/88) /
71LHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY _
7E
E: CA-00,,~- C'.
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El / 4
8% x 11 inches in size. Ch /k Rreisio7td prev(ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNE / PR PERTY LOCATION
~.o Q/ d 'ak1'/e, S p?7 T , N, R E (or)o
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CI, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBE
6
l,~J O
4
ITY
II. TYPE OF BUILDING: (Check One) State Owned VILLAGE : NEAREST ROAD
• ~Cr aoN
❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms! A EL AX NUMBER(S)
111. BUILDING USE: (if building type is public, check all that apply) 3~^l/~UiCj
1 ❑ Apt/Condo ~v
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 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2. Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E1 Repair of an
System )4ystem 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 9Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
QQ G , AFeet :;;Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New )Existing Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank - 71~ Z*&g~ pall I F1
Lift Pump Tank/Si hon Chamber , [A I El U__ El [I I El
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's y a (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's dress (Street, City, State, Zip Code):
p G/~ 00
IX. UN DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing A nt Signature (No Stam )
Surcharge Fee)
Approved El Owner Given Initial a,$-
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
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.
Ill. 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 13% 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 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 for resale by owner/contractgr,("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 _ ~~i~ r^v ~So .
Location of Property It, Section 7 T N - R W
Township
Mailing Address y- o2 a5
Subdivision Name
Lot Number '
Previous Owner of Property uE/
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for resale (spec house) ? Yes _ >e No
Volume OR and Page Number 7 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3.• Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTV OWNER CERTIFICATION
I (We) eeAti.6y that att statemewt6 on thiA 6o4m ane true to the befit o6 my (oun)
knoweedge; that I (we) am (are) the owner (6 ) o6 the pnopeA ty du cAibed in th.i,a
in6onmati,on 6onm, by viAtue o6 a wa4Aanty deed neeonded in the 066zee o6 the
County Regi4 to o6 Deed6 a6 Document No. ,,,?7 and that I (we)
pnes enttey own the pnopos ed A to bon the 6 ewage pos 6 ystem (on I (we) have
obtained an easement, to nun with the above de6eh.ibed pnopenty, bon the
con6tnucti.on o6 said system, and the same ha,6 been duty neeonded in the 066tee
o6 the County Reg.eeten o6 Deed6, a6 Document No.,,--) 76 Z -3 ► .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
i
DOCUMENT NO. WARRANTY DEED II
STATE OF WISCONSIN-FORM 9
27673'5 THIS SPACE RESERVED FOR RECORDING DATA
THIS INDENTURE, Made by Richard Fl.andri_ck and REGISTERS OFFICE
Cyrella 1~'J andrick, husband and wife ST. CROIX CO., WIS.
loth
Recd for Record this------
grantor s of St. Croix County, Wisconsin, hereby conveys and warrants day of___J_'zne _____A.D.I9 6)I
to Harold Olson and Barbara Olson husband and wife
Regis ~r f D eds
grantee S RETURN TO
Of St. Croix County, Wisconsin, for the sum of
One dollar and other valuable considerations
the following tract of land in St. Croix
County, S~atef Wisconsin;
East half of Northwest Quarter (Ej of NW4) Of Section 27 Towns',ip 31
North. ha.nFe 18 West, St. Croix County, Wisconsin
The parties of the second part herehv assume arld agree to pay a mort<<age
in the amount of v;3463.42 to Bank of New iliehmond, recorders March 30, 1964
in Vol. 402 page 373
IN WITNESS WHEREOF, the said grantor S ha hereunto set their hand _s and seal S this 26
day of June -,A.D., 19 64
.
SIG A D SEAL D IN P SENCE OF X.;rd_7(SEAL)
Richard Fla.ndrick
ri lA L°✓ _ f c~ i ct f i Z' (SEAL)
Wm. W. Ward ~ Cyyrella Flandrick
(SEAL)
Lorene Johnson (SEAL)
STATE OF WISCONSIN, i
St. Croix ss.
County.
Personally came before me, this - 26 day of Jung , A. D., 19 64.
the above named Richard Fla.ndrick and Cyrella Flandrick, husband arrl wife
to me known to be the person 8 who executed the foregoi Oki nd acknowledged the e.
Wm. W. Ward
This instrument drafted by Notary Public St. Croix County, Wis.
Wm. W. Ward My Commission (Expires) (Is) FerMRnent
(Section 59.51 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly printed or typewritten thereon the
acmes of the grantors, grantees, witnesses and notary).
Of L f1 4
WARRANTY DEED-STATE OF WISCONSIN, FORM L 96 P~i~E J ~J H. C. HILLER CO., MILWAUKEE
z
STC - 105 r
r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
t7
a
OWNER/BUYER 62'~
ROUTE/BOX NUMBER Fire Number'.;&_
CITY/STATE zp`~ -ZIP-, 41,7
PROPERTY LOCATION: , )V&/k, Section o~ T lam/ N, R--C- W,
Town of ~jfc~ r ~u y r , St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior.to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site 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
0
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
~i~ro~'~ N 9
DATE St. Croix County Zoning Office
P.O. Box 98t
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IN'DUS'TRY; DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 3707
HUMAN RELATIONS
I L!i R 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNSHIP UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
/T N/ (o rrr -c
C UNT : MAILING ADDRESS:
USE DATES OBSERVATIONS MADE 6
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PERCOLATION T :
®
Residence ❑ New .Replace 7„
O
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑U EgS ❑U S [:]U El S U ❑ S [2U
4, 41eoe~
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: a _az Floodplain, indicate Floodplain elevation: D
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HI HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B- ® a Ile' 7
B- U l B -L~ -7
B-
B- z.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES
f NUMBER FARM AFTERSWELLING INTERVAL-MIN. PERIOD 1PERI D2 PERIOD PER INCH
P- e~ a •--P O Ile
P- d 3 7-Z 452
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.
I
E
I
14
,
,
U <40 e- l I d ~f7.✓ r. L r ~ d dad- r~ j
E ,
,
_tj
//its s r
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:
/2 - v? 3
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
n D /J- gE
CST SIG ATUR :
C
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
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
Is - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand - Less Than
'I - Loam Bn - Brown
- 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.
i
PLOT PLAN
PROJECT l/ar~1 O~t~h ADDRESS /a, ll/ ~/~D-
1/4 ff/ 1/4/$ lT~~ N/R., ~ TOWN 6g, ~c COUNTY S,=Groin
PRS Byron Bird Jr. 3318 -DATE
BEDROOM -;?CLASSPERC~Y7Z~ CONVENTIONAL ~IN-GRO PRESSURE
CONVENTIONAL LIFT_ MOUND_ HOLDING TANK
SEPTIC TANK SIZE IFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA , ERC RATE BED SIZE
b Benchmark V.R.P. Ass~fe Elevation loo-
Location of Benchmark g/
* H. R. P.
E3 Borehole Q Well Scale = Feet
0 Perc Hole System Elevation
Uent
12"
Grade
TYPAR COVERING
2"
12" 3- 4 g- 0 3-
Sewer Rock
1.2-
r
40 a
L10, 0 1 f
-
- ~
y
60