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• Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER L_,E> f f / G eC° SEC. v T 13 N-R ~co W
ADDRESS /-Qu ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE ~:22: I
PLAN VIEW
Distances and dimensions to meet requirements of ILUR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
i
1
~ ~ UcJ L L G
13 '
INDICATE NORTH ARROW
BENCHMARK: 'Describe the vertical reference point used plz,^,,Cs-r
Elevation of vertical reference point: ~Q • ~47 Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: ~ fS Tank Outlet Elevation:
?57
Number of feet from nearest Road: Front,O Side Rear,19% feet
vc.Y 0
-From nearest property line . Front,OSide,~Rear,O feet
Number of feet from: well , building:
(Include.this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE_REVERSE_SIDE.
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, Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench: -X
Width: Length: Number of Lines: D ~G Area Built: Fill depth to top of pipe:
.Z
Number of feet from nearest property line: Front, Side, O Rear, O Ft
Number of feet from well: 6 S
Number of feet from building:
(Include distances on plot 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, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
1 ~
Inspector:
Dated: / Plumber on job:
License Number: i
k
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
,SIQDISRh WI 0 O T31-R16 State PlanIned.).Number:
O
Town of Cylon ❑ CONVENTIONAL El ALTERATIVE It assi
State Hwy. 46 ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO DAT
i
Ludvi Kram ert 12203 Hw . 46 Deer Park WI 54007
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
L le J. Ayers 6219 St. Croix
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PROVIING LABEL LOCKING OVER
DED:
❑ 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: TNO. OF RENCHES: DISTR. PIPE SPACING: COVERIAL: INSIDE DIA.: # PITS: LIQUID
PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: RINLET-
I I T:
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
SEEDEDMULCHED:
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: 7SODDED'_
CENTER: EDGES:
ES E] NO ❑ YES E] NO ❑ YES -1 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: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: ID A.:
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-*
1 1-
G .9,
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION
=..7700, c
. In accord with ILHR 83.05, Wis. Adm. Code OUN
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 105-3-7
8% x 11 inches in size. ❑ Ch k i revision previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PRO RTY LOC 0
'/4 "10 %4, S T3 , N, R / E (or) W
Z5 IW C A~,_ - )W
PROPERTY OWNER'S MAILIN ADDRESS LOT # ( BLOCK ~p
/tJ
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
c Girl
'7X55? -7
II. TYPE OF BUILDING: (Check one) CITY ! !J ~cJ NEAREST ROAD
State Owned ❑ VILLAGE
❑ Public K1 or 2 Fam. Dwelling- # of bedrooms J__ PARCEL TAX NU BE
III. BUILDING USE: (If building type is public, check all that apply) -2
1 ❑ Apt/Condo (o
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.E1 New 2. .Replacement 3. ❑ Replacement of 4.0 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 Seepage 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
cw oil
57 Feet Feet
L- .2 .2SZ? , G 26
VII. TANK CAPACITY Site
in alIons Total # of Prefab. Fiber- Exper.
New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
INFORMATION
Tanks Tanks structed
C F1 I L1
Septic Tank or Holdin Tank 1006 00e__
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.
Plum er's Name (Print): Plumber' ignat e: (No Stamps) P/ PRSW No.: Business Phone Number:
P is Address (Street, City tats, Zip Cc
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Ts--d---j Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial / - 613 Surcharge Pee)
Adverse Determination
-
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
f
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.
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
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/contractor,(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 do-)-fi/4 1/4, Section, T _N-R_/
Township
Mailing address
Address of site - C~
Subdivision name 1 ti
Lot number
Previous owner of property
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 No
Volume c3and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. 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 Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. --2 °3.;P
S, ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been dul rec rded in the Office
of the County Register of Deeds, as Document No.
CIL,
Signature of Own r Si nature of Co-Owner (If Applicable)
Date of Signature ate,,of Si nature
X u.280. warrauty Deed-To Husband and Wife DALIlt L. `IMS. PublUbad by In Cleln Beek • Otago" p,
.262336
Tbiz 3lubenturt, Made this 5 th day of July ~ lg 60
between Eunice Jones, a widow, the surviving wife of Neale V. Jones, deceased:
part y of the first part, and
Ludvig Krampert and Myrtle V. Krampert,
husband and wife, as joint tenants, parties of the second part.
Witn9000tj, That the said part y of the first part, for ant, in consideration of the sum of
Seven Thousand Five Hundred ($7500.00) Dollars,
to her in hand paid by the said parties of the second part, the receipt whereof is hereby
confessed and acknowledged, ha s given, granted, bargained, sold, remised, released, aliened, conveyed
and confirmed, and by these presents do e s give, grant, bargain, sell, remise, release, alien, convey and
confirm unto the said parties of the second part, as joint tenants, the following described real estate
situated in the County of St. Croix , Wisconsin, to-wit:
Commencing Thirty-four (34) rods South of the Northwest corner of the
Southwest Quarter of the Southwest Quarter (SW4 of SW4) of Section
number Eight (8), in Township number Thirty-one (31) North, of Range
Sixteen (16) West, St. Croix County, Wisconsin; thence South nineteen
(19) rods; thence East fifteen (15) rods; thence North nineteen (19) rods;
thence West fifteen (15) rods to place of beginning, subject to highways
and that part heretofore taken for highway right of way.
Also certain personal property located on the above described real estate
that is specifically described in a Bill of Sale of the same date hereof.
J
.y 1
I' . N
1 _
COgttbM, with all and singular the hereditaments and appurtenances thereunto belonging or in anywise
-r appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part y
of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained
premises, and their hereditaments and appurtenances.
Co babe anb to Kolb, the said premises as above described with the hereditaments and appurtenances,
unto the said parties of the second part, as joint tenants.
Xnb the ftstb, _ Eunice Jones, a widow,
part y of the first part, for her, her heirs, executors and administrators,
L does covenant, grant, bargain and agree to and with the said parties of the second part, and to and
with the survivor of them, his or her heirs and assigns, that at the time of the ensealing and delivery of
these presents she is well seized of the premises above described,
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sop aoazeip aa)3ra.aaaL3 zo payatzd trujuta ass4 rrugo Pap.ioij," aq of rtaataazluar rto ;8" saprsozu MILON '■rb 09 '413-•9W)
6t ` t ~ttat►a s,sin~ a .cv vista jdaaSatttr aq os) saJrdza uorssrururoa L/~l ,
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•paure;uoo urazagi sasodznd atp A d aqi
pa;noaxa aq s ;eg; pa2palMOUXoe pue;uaurnz"sur urq;Fii aq; o; pagrzosgns sT aunrW@i A UOSJad
aq; aq o; (uaAOzd dlrJ0;oelsr;es 10) UAIOrr71 ' ' MOpTM e ' Sauo j aolung pwwadde
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(teaS) " ' _ 'vy,• s~~ ~'°~_r leas
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pue pueq zaL1 ;as o;unazaq s eq;szy aq; 10 A ued pies ag; `103334M OOugjM uC
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aqi 1o sar;zed pies aq; to uorssassod algeaoead pue ;arnb aqi ur `sasrruazd paureBJeq aeoge aqi ;eq; pus
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER qt
ROUTE/BOX NUMBER FIRE NO. c~L}
CITY/STATE. ZIP
PROPERTY LOCATION: o 1/4 1/4, Section T.=!~LN, R-1-L_W,
Town of , St. Croix County,
Subdivision , Lot No.
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED 4,
DATE /G
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
7969
LABOR AND PERCOLATION TESTS (115) P.O. BOX
3707
HUMAN RELATIONS MADISON, WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOW SHIP/MLIC~IGiPA~': LOT NO.: BLK. NO.: SUBDIVISION NAME:
FL /T3/ 5 W '/4 6 W'14 NIR16X(: COUNTY: O ER'S NG ADDRESS:
iil;~~2603 STS w 6
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: I
a0esidence ❑ New Replace /0- o j~+ q
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONtA''L: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FFILLHOLDIING(TTAA'N~K: RECOMMENDED SYSTEM: (optional)
r2soV~ QQJ 2U ~cJ r_111 ~ ~c`J .WU I ~ cJ HIV
If Percolation Tests are NOT ESIGN ATE:
required 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 EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-~ p'79 > o 1)_9" 3 7- z 0 6A.,Q t-1
B- 6Q 19 51- >6o -36 ,t3 36-6o ti
B- ~ D b- /o o - S- o ~ ~
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R IOD3 PER INCH
P_ 13
P_ p 9 S / '
JA f.
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
pR~s N '
Y' &,Af
IHW)I DAn~,6w.41 A4 tOR T61,48
L16 13 is On el
'S LON
E ,
TN
E
I ! M
'2 "Zo io PC
3
r E
ko r S IzF:'.9cR 5 .
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.
NAM rint►: TESTS WERE COMPLETED ON:
r AD E CERTIFICATION NUMBER: PHONE NUMBER (optional):
T S NATURE: f
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
TINS a - n .ONE COMPLETING FORM 115 - - 395
yor.€r
2. use sec ' 3, ~ind ethe€ ties is a r- ~ cornmercial r)
3. PJIAr llt?UM r~ , .mercial us(. pl<.,
4. Is this a r." sy:' err
a. g boxes- A SITE IS SUITABL IOLDING TANK ONLY IF ALL
- RULED OUT BASED ON
3. PL , - .ns shov"m here for wr:~= ~r,' and completing the plot plan;
7, MA, :I ar;curately locatir, ° >cations. Drawing to scale is preferred. A.
sr d sirscl;
Vertical elevation nt are cle i, and are permanent;
€,=s- a€x ria~, s ~o dates, namms, les, flood plain .°a, percolation test exe€np-
1C. he infor rma-,n (such 'n, rr levatio;n) does not appahy, place N.A. in the appropriate box;
11- Sign the form and place yow 'dress and your certification numbers
12. Make legible col)ies and distribute as required. ALL. SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL 1 R
Soil Separates and Textures Other Symbols
st - Stone (ever 10") BR
cob Cobble (3 - 10") SS lstone
gr Gravel (under 3") LS - ,tone
*s 5r` nd HGVI High Caro -ter
cs - C else Sand r' percolat'.
Ined, iurn Sand , tell
Sand B, d--
is
- ;r,- Bn ,an
,..F i MV
Loam 1,
Silty Clay fif faint
x, c _ Clay cc , - coarse
pt - Peet m€T: r ed"Im,
ivluo< d
t>I
1-1lVL High rk`,
surfar,
BM - Be-n€_",
VRP Vertic-3 .,1Ce Poirlt
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.
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