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HomeMy WebLinkAbout038-1160-30-000 ~ o I a> o Q> 3 0 p ac c 'I o i' I o I, ~ N ~I, I I Z3 y I I ~ I m LL c OLD I O i R ' Q I T Ili . O M z h U) y o v £ Z ~ d a I CL m M z o E 6 v o zv' ° v o o N H CD Z c E o m '0 O_ N y c I N N • O .c IL N co V N a Zco z Z c c E N co Cil o6 d s m c c C m o c ~p ~ m ~ a ° E G c a E CO O N U) (q V) N d m O 00 O O O ° •N N E a a a U a o 4.; E m C U ~ 3 0 0 N J U 0) rn } _ Z Zn in (n N N Y L C 0 E C) O c0 d ~ m ~ c I Lo m Q~ } m O I ~j O N N o 3 w c is 04 ce) O p ~ I' N N N LL O O C,) a 0. CL n E E o rn p c°o cu (D o o 0 _ N C r LL L N F- I- N r O M -t aYi Lo ea v~ E E • t8) M (n Y O Z UJ O ~ I \ w E £ a w 0 CL 9 4) (D rr~~ "'1 3 0 N U ' Q U a2 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT r ~ OWNER /~f G. _ 4 TOWNSHIP ✓ct DTI ~o` SEC . T j_N-RW ADDRESS G~ ti r ~rST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y' Sao All y INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used X/lo Gyf Cs Elevation of vertical reference point: / Proposed slope at site: SEPTIC TANK: Manufacturer: /iC~-t e If Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Ai-L,-~- Tank Outlet Elevation: Number of feet from nearest Road: Front ,(Side 0 Rear, O / feet -From nearest-property line t ' Front, 0Side ,0Rear, 0 feet Number of feet from: well ///a building: `j (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE f 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: Trench: Width: l _ Length: Number of Lines:- Area Built:~_ ~5 - Fill depth to top of pipe: Number of feet from nearest property liner Front, O Side-,6 Rear,O Pt. Number of feet from well: Number of feet from building: (Include distances,gn plod plan): SEEPAGE PIT 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, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR r' SAFETY & BUILDING DIVISION LABOR & HUMAN RELATIONS P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION M ISON 1 53707 State Plan I.D. Number: S[nfi4, Sec. 34,T31-R18 (If assigned) Town of Star Prair ®CONVENTIONAL ❑ ALTERATIVE S 1 ~ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: :=22YOrCloutier OFPE~RMIT HOLDER: INSPE TITEMike Kiekhoefer Dr.,Somerset, WI 5402 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. EL 3 ST REF. PT. ELE /dd.U 1 ( 2 I r o-4 a Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Byron Bird Jr. 3318 St. Croix 135510 SEPTIC TANK/HOLDING TANK: Z' MANUFACTURER: LIQUID CAPACITY: TANK INLE TANK OUTLET ELEV.: WARNINGEDLABEL LOCKING COV ~e , PR VID PROVIDED: ~jJ~~~ , 9~, YES ❑ NO ❑ YES NO BEDDING: DIA.: >JGOIT-MATL.: HIGH WATER NUMBER OF ROAD: PROPERT WELL: BUILDING: VENT T FRESH ALARM: FEET FROM LIN I+ t AIR INL~Fj 1 ❑ YES NO ❑ YES NO NEAREST -1 If DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING OVER PROVIDED: ROVDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH FEET FROM AIR INLET: (DIFFERENCE BETWEEN 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 intns? wire, construction shall cease until MAIN the soil is dry enough to continue., CONVENTIONAL SYSTEM WIDTH: LENGTH: NO. OF CING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH I~ 1 TRENCHESRIAL: PIT DEPTH: DIMENSIONS 5 161 MR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE A RIAL: jPIP LINE: ^ AIR INLET: low BELOW PIPES: ABOVF~ COVER] ELEV. INLE ELEV. END: FEE T FROM : NEAREST, MOUND SYSTEM: 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: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: N0. 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 in in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: SBD-6710 (R. 06/88) s I~HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1261S10 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. Gc,~ PROPERTY OWNER l PROPERTY LOCATION )`ye. _"G r- '/a, S T , N, R E (o PROPER OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, S MATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE : NEAREST ROAD 19 f o t1 S ❑ Public 101 or 2 Fam. Dwelling of bedrooms PARCEL TAX N MBER(S) 000 `,,n~ - O® III. BUILDING USE: (If building type is public, check all that apply) (L 1 ❑ Apt/Condo 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 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. D9 New 2. ❑ Replacement 3.E] 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 n Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 420 Pit Privy 130 Seepage Pit Pressure 430 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 (s q. ft.) PROPOSED (sq. ft.) (Gals/dady/sq. ft.) (Min./inch) 9 ELEVATION L4 S0 dox" I L p Feet CO-~ Feet I V7 115-4 VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks oncret structed glass App. Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number: /J , r,/ Plum ddress (Str t, City, State, Zip Code): IX. C LINTY/DEPA T ENT U8 ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued issuing ent Signa a No Sta 2Approved ❑ Owner Given Initial Surcharge Fee) 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." II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. 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 9TC-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 ptzmIt Issuance. -Should this development be intended tot tessli by ownst/conttactot,(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 Location of property )v i/4 -'s /it section T~.M-E L-w township • ~S7~ s- ~.~7kA ;A1 -e Malting address _ 22.E C) G,1.11,--elA Or /bpf s o f /d 5 Address of alto Subdlvlslon ' X;i, • Lot number Previous owner of property Total also of parcel Date parcel was created a 6 Are all corners and lot lines identifiable? as 0 Is this property being developed to tamale tepee house)? as e volume ind Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWIN01 A WARRAXTY DEED which Includes a DOCUMENT NUMaRR, VOLUME AND PAOt NUMAnt and the 82AL OF THE RROIBTRR OP DRRDB. In addition, a certified survey, It available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Cestitled Survey Map, the Cottifled Survey Map shall also be required. ---------------------------------------------------------7--------------•-•---- PROPERTY OWNER CERTIFICATION t(ve) certify that all statements on this torn are true to the best of or (out) Rnovledge) that I (we) am (are) the owner(s) of this Information form, by vlttue of a warranty deed tthe co pcrdedopstInty dethescrcribeed in at the county Register of Dead* as Document No. I and that I (we) pceeently own the ptoposed site tot the sewage dl posal ystew (at I (we) have obtained an easement, .to tun with the above described ptopetty, tot the construction of sold system, and the same has been dui tar ded in the ottice of the County Regis ec o as Document No. 1. V Signature of ownee Signatute of co-owner (i APO icabMI ate of ignsturs Date of Signature Lot Thirteen (13) of Germain and Hanner Addition to the Town of Star Prairie, being located in Township Thirty-one (31) North, Range Eighteen (18) West. f A parcel of land located in the Northwest quarter of the Southwest quarter (NW4 of SW4) of Section Thirty-four (34), Township Thirty-one (31) North, Range Eighteen (18) West, Town of Star Prairie, described as follows: Commencing at thg West quarter corner of said Section 34; thence North 89 49140" East (true bearing) 38.00' along the North line of said Southwest quarter (SA) of Section 34 to the point of beginning; thence North 89 49140" East 1284.79' along the North line of said Southwest quarter (SW4) of Section 34; thence South 0°07'13" West 555.69' along the East line of said Northwest quarter of the Southwest quarter (NW4 of SW4) of Section 34; thence South 89°49'40" West 867.771; ' thence North 0°07'04 "East 489.70' along the East lines of Lots 12 and 13 of Germain and Hanner Addition; thence South z 89 49140" West 417.00' along the North line of said Lot 13; thence North 0007104 East 66.00' to the point of beginning. This parcel contains 11.70 acres, more or less. This is an addition to an existing parcel and a substandard parcel is not created hereby. to SEPTIC TANK MAINTENANCE AGREEMENT rt St. Croix County OWNER/ BUYER rt 0 p 5~ ROUTE/BOX NUMBER Fire Number :3 aG C ~ i CITY/STATE ~W c~ r~/ zip 'oldi f rt M PROPERTY LOCATION: ,S k) k, Section, TV N, R~W, Town of A AA - I ~ St. Croix County, Subdivision Gf~`f" &,nv,~ Lot number-,/ -3 Improper use and maintenance of vour 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'eptic tank pumper. What you put into the system can affect t e .unction of the septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents may be eligible to recieve a grant for a maximum of 60K 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_tems 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 ora 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 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. ZI > SIGNED DATE 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 & BU 'LDI _ IN~USFRY, P.O. BO~C~$ LAFsUR AND PERCOLATION TESTS (115) MADISON, Wt HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) UNIC PALITY: OT NO. LK NQ.: SUBDIVISI, NAME: USELEW LOCATION: SECTION: WN tz e COUNTY: MAI LIC/ADO SS: 'r f , s USE DATES OBSERVATIONS MADE ttt~~~ NO. BEDR C OMMERCIAL DESCRIPTION: 15ROFI LE 0eSCRUrrlONS: lrtnuut^ I M-TEFFNI-111 q~ 7 rtl Residence ~j .,.w► ,WNew ❑Replace RATING: S= She suitable for system ` U- Site unsuitable for system ONV NTINAL: MOUND: ' IN-GROUN r-111 -IN-FILL OLDING TANK: SYSTEM:Eoptjonall ,.ro S oU fL~CU S ❑ uT U [IS 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: 3Q Floodplain, indicate Floodplain elevation: h PROFILE DESCRIPTIONS BORING TOTAL QFPTH GROUP DWATER-INCHE_S CHARACTER SOIL WITH THICKNESS, C LOR, TEXTPRE, ANQ NUMBER DEPTH IN. ELEVATION OBSERVED TO BEDROCK IF OBSERVED SEE ABBRV.ON'BACK.) B- 16q 140t A119 Ile 157V B- If rya. 2 Ale --c- _:;;i!Fy i PERCOLATION TESTS DEPTH • WATER IN HOLE TEST TIME -DROP I WATER LEVEL-INCHES RAPER IN H NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD I D2 P. P- Iii O i' P itA. P T P. PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate,scale or distances. Dgeciribe what are tlMt" p1tl~ zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at ill boring; and the direction," of land slope, / f ° ~d Fr SYSTEM ELEVATION_ ~r. I ~.6 X: JA 0;~ Yl: - 3 12, J .40 -0 ado t r t R f P'~ o Pei /L A S°yi: I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and`metitods specified in the Wi ` 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: C ✓ T•7 ilp ADDRESS. CERTIFICATION NUMBER: PHONE NUMBER (opt CST SIG URE- 4F 8 : h= DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDdJSTEiY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNS UNICIPALITY: OT NO.:BLKC NO.: SUBDIVISION NAME: /T3 N/R /~E ( ) W _ L~ A r _ COUNTY: ILING ADD ESS: ' M2 lizal GiQ ~ o er r~6/2~~7V-r . S--,wer e~- 64)/ USE DATES OBSERVATIONS MADE S: ER A I STS: NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL Residence New ❑Replace 7Y _ RATING: S= Site suitable for system U= Site unsuitable for system r O~NTIOaNU . Mil. ~Y IN-GROUND-PRESSURE: URE: SYSTEM-IN-FILL O~LDINGNK: RECOMMENDED SYSTEM: (optional) 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: -e 3© 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. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ( 1x jon . 2 /YOB B- IF 13, -,9 OL4149 1--e B- L PERCOLATION TESTS EST DEPTH. WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD3 PER INCH P_ ® f P- 07, J 7r P- X j5 P- P- LP- 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 I ~ i i F lux x = ; , I i lei' - w. 10 3 3 E i 3 ~ _ d [ 3 t ~ F , s 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: ADDRESS. CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGN TU E: 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 fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand 'c - Less Than 'I - Loam Bn - Brown 'sil - 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 PLOT PLAN PROJECT WZ ~ ~e/ DDRESS o?~XO Gl~f eO" s s you laA14 1/4/s, ~ l N/F~/I(W TOWN_ r d iHi•` QOUNTY -Lro MPRS Byron Bird r. 3318 DATE G BEDROOMS CLASS PERC_ CONVENTIONAL IN-G UND PRESSURE CONVENTIONAL LIFT MOUND_ HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE v2,47- BED SIZE ,lzS L Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. ~!!~Z?< ❑ Borehole Q Well Scale Feet 0 Perc Hole System Elevation Uent 12" Grade TYPAR COVERING 2" 12" 3' 4 g' ® 3' I 6" Sewer Rock i 12' ~ /dam t tile bi3 a'` 4 S ST. CROIX COUNTY ZONING OFFICE v St. Croix County Courthouse 911 4th Street i Io " Hudson, WI 54016 Telephone - (715)386-4680 To 'he St. Croix County Zoning Office offers the service )f septic And water inspections to Lending Institutions, Realty Flrms, and )rivate individuals. 'ompletion of this form is essential so that the property can be .ocated. lease provide the following information, enclose ap)ropriate ee made payable to St. Croix County Zoning Office, aid mail, along with form to the above address. Testing will be done as ;oon as possible after fee and form are received. TATER TESTING----------------------------FEE: $ 25.00 XXX (For nitrates and coliform bacteria) LATER TESTING FEE: $127.00_ (For VOC'S) ;EPTIC SYSTEM INSPECTION-----------------FEE: $25.00 (Determines if system is properly fun nin at t.me of M inspection) C OIG~O lT ,roperty owner's name Michael and Kat Kieckhoefer l ,roperty owner's add e s 1845 - 110t ew Richmond WI 54017 D egal Description 1/4 of the 1/4 of Section, T N-R , ''own of star Prairie Lot Number Subdivision Name Germain & Hanner 5J Addition 7 'IRE NUMBER 1845 LOCK B J 'olor of house Bile Realty sign by house? If so list firm: Last house on Road .,LEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF P.AT BOOK, '7ITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. 'esting of residential water requires a sample that is flesh. If .he home is vacant, and has been so for some time, the water line Lust be purged by running the water for several hours b,fore the est can be conducted. (INTER TESTING: Many times water lines are turned off, or sill -ocks are turned off, making access to the home necess,ry. If :his is the case, please make proper arrangements w th this ,ffice to ensure time when entry may be gained. 'irm or individual requesting services: Bank of Somerset 'elephone Number (715) 247-3348 ;.SPORT TO BE SENT TO: Arlene Reardon, Bank of Somerset. P-0- Row 220, Somerset, WI 54025 losing date mW=4 S. 1924 ignature ***PLEASE CALL KIECKHOEFERS AT (715) 246-4621 TO MAKE APPOINTUMT F VATER C• w J S 81 N LAND SURVEYING • HUDSON , WISCONSIN 54016 (715) 386-2007 NAME Bank of Somerset ADDRESS Somerset, Wisconsin 54025 DESCRIPTION Lot 13 of. Germain and Hanner Addition to the Town of StAt Prairie. Also a parcel of land located in the NA of SA of Section 34, T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin. PLAT DRAWING N This is not a complete Land Survey N8904914011E 1284.79' 0 0 N8904914011E 417.00' ~0