HomeMy WebLinkAbout012-1012-50-000
Form -STC-104
AS BUILT SANITARY SYSTEM REPORT
OWNER C GLG JI~~ r ~ TOWNSHIP SEC. T./o N-R/
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
119
K
j lJ0
3 a~ Ld
INDICAT NORTH ARROW
BENCHMARK: Describe the vertical reference point used 6ff~ o S<C//.
Elevation of vertical reference point: Proposed slope at site:_
SEPTIC TANK: Manufacturer: ~~Gt3 Liquid Capacity: ld'a-a
rµ~~ Number of rings used: --tom= Tank manhole cover elevation:
Tank Inlet Elevation: 7 7 ~ Tank Outlet Elevation: ~Jr~ r
Number of feet from nearest Road: Front ,1Side,oRear, OQ feet
.From nearest property line Front, 0 Side,ORear,O feet
Number of feet from: well , building: A< /
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SRR REVERSE STDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlets 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:
i
Width: Length: Number of Lines: _ Area Built: 30~
Fill depth to top of pipe:
Number of feet from nearest property line: Front, 0 Side, 0 Rear, 0Pt
Number of feet from well: ~e2
Number of feet from building: ell
(Include distances on plo plan).
SEEPAGE PIT yG~ g6lS f-
Size: Number of pits: ! Diameter: ,
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box0 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:
Inspector
Dated: Plumber on job: License Number: 3 /
3/84:mJ
DEPARTNWNT OF INDUSTRY, SAFETY & BUILDING
LABOR & HUMAN RELATIONS INSPECTION REPORT FOR DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707
State Plan I.D. Number:
1 SvY -,j S4, T3ON-Pd 7W (If assigned)
Town of Lrin Prairie Ea CONVENTIONAL El ALTERATIVE
El Holding Tank El In-Ground Pressure ❑ Mound U
7nf
A P L ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Joe pia tbERER: h Route 3, Box 207, New RichTend, WI 54017 °T ~
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:
Byron Bird Jr. 3318 St. Croix 119459
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEY.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
7 ~ (/J / 7♦ 5 e PROVIDED: PROVIDED:
(i ES ❑ NO ❑ YES O
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LIR AIR IN ET:
❑ YES O ❑ YES ❑ NO NEAREST ----~-d`~
DOSING C AMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ 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 F-1 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.: # PITS: LIQUID
/ -7 - TRENCHES: 4; r M ERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: V. l 7i ELEV. ENp: PIPES: FEET FROM LINE: f / AIR INLET:
,V 2 ~L NEAREST 00- Jam/ Z C Z S
MOUND SYSTE :
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:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
MBER OF PROPERTY WELL: BUILDING:
PERMANENT MARKERS: OBSERVATION WELLS: $AREST-_
COMMENTS: ET FROM LINE.
❑ YES ❑ NO ❑ YES ❑ NO ~
ow ba Har, ~er,~ (sp,~.
C Q~
6, G
Sketch System on / J JSIGNATURE;.,-- Retain in county file for audit.
Reverse Side. ( TITLE:
Zoning Administrator
SBD-6710 R. 06/88
D~LHHSANITARY PERMIT APPLICATION
COUNTY
E:7R DILF R In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 9.116- 9'
8% x 11 inches in size. ❑ Check if revision to previous application
wee reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
t aG hll-0w /0 '/aEe1 S TD , N, R E (or
PROP TY OWNER'S MAILING ADDRESS OT # BLOCK #
3,6e 0,7 GGj / 2~ - -
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ CITTLYi4GE r 4 r;7 NEAREST ROAD
❑ Public V" or 2 Fam. Dwelling-# of bedrooms PARCEL L/Ax NUMBE
III. BUILDING USE: (If building type is public, check all that apply) ? 0 - `Q~
10 Apt/Condo
2 ❑ 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
50 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. ❑ New 2. 9 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 8 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 (s q. ft.) (Gals/day/sq. ft.) (Min./inch) _ ELEVATION
5~0 9,7''~Feet 9 Feet
VII. TANK CAPACITY Site
in allona Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
0r ^
Plu er' Address (Street, City, State, Zip Cod
4e,-
IX. C UNTY EPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (No Stam s)
IRApproved ❑ Owner Given Initial surcharge Fee) ' q
A v D ti lry' ~~/1
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
t r
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-8398 (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.
-
'j 0 12.
twner of property
Location of property ~U 1/9 SuJ 1/4, Section , T 30 N-R l7
Township
Mailing address 3 ge It>
Address of site -Sig/4t 2 .4 9Zod-c,
Subdivision name
Lot number ft-
Previous owner of property ,9
Total size of parcel 3 /~►Cdc S
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 --and Page Number v 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
1(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 de joded in the Office of
the County Register of Deeds as Document No. ; 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
const Lion of said system, and the same has been duly recorded in the Office
of t e C unty Registe of Deeds, as Document No.
Signat a of 0 Aner Signature of Co-Owner (If Applicable)
9 Date of Signature Date of Signature
DpCUMENT No. WTE BAR OF WISCONSIN FORM 1-1982 I THIS SPACE RESERVED FOR RECORDING DATA
ii WARRANTY DEED
I
55 22= aa- REGISTERS OFFICE
ST. CROIX CO., WI
This Deed, made between li Re-.'d for Record
II R.abe_r_t---B_._-_D antan...arnd-_Ali_ce.._M___Oantan ~I
89
husb-and__and...wi-f_e-_-as.__sur-u_Lvo_rshi{~---m-ard-ta.L.•.... JAN vl 1tV
I~ pr.opar_ty---------------------------------------------------------------------- Grantor, ii at 9:00 A/M~
li and------ Jozy---R_---Ha-ckhar-th---ari•d---Dan•a--L.------ Fia-kbar-th......... ~~r~,,,~,t~'3C.
-__.....___hush-and.-a-nd---wa•£e---aa_m-ari.ta-l---sure-iv-ar-chap---•.. I~ Register of Deeds
r.o , er- !I
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration...... I
I RETURN TO O
•---------R-abar.t...ar-1-d- Ali.ce---Dantan-------------------- I: RE_ -
conveys to Grantee the following described real estate in t..... Gr'o.i.x......
County, State of Wisconsin:
A parcel of land located in part of the
Southwest Quarter (SW%) of the Northwest Tag Parcel No: _..x.12.........
Quarter (NW%) and the Northwest Quarter
(NW%) of the Southwest Quarter (SW%) in
Section Four (4), Township Thirty (30) North, Range Seventeen (17)
West, further described as follows:
Commencing at the West 114 corner of said Sec. 4, said corner also
being the Point of Beginning of this description; thence S00 degrees
II 30'5011E along the West line of said SW4 1328.26 feet to the
Southwest corner of said NW% of the SW%; thence N87 degrees 20158"E
along the South line of said NW% of the SW% 1306.22 feet to the
~j Southeast corner of said NWa of the SW%; thence N00 degrees 26135"W
I~ along the East line of said NW% of the SW%, 1316.46 feet to the
'I Southeast corner of the SW% of the NW%; thence N00 degrees 1613011W
along the East line of said SW4 of the NW4 88.00 feet to the Southerly
right-of-way of the Soo line Railroad, said right-of-way being a
5506.82 foot radius curve concave Northerly whose central angle
measures 4 degrees 08153" and whose chord bears N88 degrees 46145.5"
II and measures 398.60 feet; thence Westerly along the arc of said curv
398.69 feet to' the Point of, Tangency; thence- N86 degrees 42!19"W aloe g
said right=of-way 7$7.60 feet to the 'point- of curvature of a 5679.65"
foot radius--ourve concave Southerly whose centt;aa.angle."meas.ores.<.'
This 7.5............ homestead property. =,continued-,%,
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And........ Robert.. end Al oe ReR
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements," restrictions and rights-of-way of record, if any.
FED
and will warrant and defend the same.
.
Dated this V day of -J--.. .anuarar 19...89
(SEAL) ' de, 4~. (SEAL)
~i M Robert B. Denton * Alice M. Denton
~I (SEAL) ......................(SEAL)
* *
I
j~
II AUTHENTICATION ACKNOWLEDGMENT
Signature (s) STATE OF WISCONSIN
ss.
authenticated this day of 19------ Personally came before me this .day of
January_.••.-•_____-_•______' 19._89. the above named
Robert B. Oenton_,._._A1-ice M.
TITLE: MEMBER STATE BAR OF WISCONSIN Denton
.
I (If not-
authorized by § 706.06, Wis. Stats.) g
to me known to be the person who executed the
for g ing instru t and a nowledge the same.
THIS INSTRUMENT WAS DRAFTED BY -
Kristina O land Lundeen
g EJ FLEISC
-----------A t t o •r n e y" a-t--Law * A 11 c e J. e i s c h a u e HAUER
S t C r t~ ~'Y•PGb1iD---
Notary Public = Df. , Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, sta iration
are not necessary.) date: -lune---1..1.................................. . 19.-83..)
-Names of persons signing in any capacity should be typed or printed below their Signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 1-1982 Milwaukee, Wis.
Don 832 615
E
1 degree 14159" and whose chord bears N87 degrees 19'48.5"W
and measures 123.89 feet; thence Westerly along the arc of
said curve 123.89 feet to the West line of the NW%; thence
! S00 degrees 4212811E along said line 196.16 feet to the Point
of Beginning.
f
I
I
iI
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER _J 12/TC~G rf~
ROUTE/BOX NUMBER .S 307 FIRE NO. l
CITY/STATE /ve- a-y ZIP
PROPERTY LOCATION: 1V& 1/4 St~cJ 1/4, Section T S0 N, R / 7 ri-D
Town of ~~i• i ~/,g..r~ { , St. Croix County,
Subdivision Lot No.
Improper use and maintenance of yourseptic system could result in its premature
failbre 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 .Cro'x County Zoning Office within
30 days of the three year expiration date.
SIGNED
DATE
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
SAFETY & BUILDINGS
D PA T M NT OF REPORT ON SOIL BORINGS AND DIVISION P.O. BOX 76
LABOR AN6 PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: T NS YNICIPA ITY:,) i LOT NO.:BLK. NO.: SUBDIVISION NAME:
Ila '/4 ~ T N R to ~
COUNTY: / MAILING ADDRESS:
~a e P p o2 D ~aal1 c UA/n Gr GlJt %Yal
USE DATES OBSERVATIONS MAD E,,.2!44 ~Ca
NO. BEDRMS.: COMMERCIAL DESCRIPTION: ~R A I E TS:
Residence -
RATING: S= Site suitable for system U= Site unsuitable for system
COENTIOENAL: M~ D: ❑u IN-GROUND-~ URE: SYSaTEM-IL O~LDING~NK: RECO~ EN~SYSTEM: (optional)
MS
DE
If Percolation Tests are NOT required SIGN RAT If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: A Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HI HIGP_EST_ TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
AdC?
/&e> Ile o:71e
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER L VEL-INCHES RATE MINUTES
NUMBER Fl~ AFTERS ELLING INTERVAL-MIN. PERIOD I PERIO 2 P R PER INCH
P_ 0 - G
-7
P-
P-
Zil 71 '4 -e-
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 ~5 =
_ P ~0 ;
rr~
C '0
3~ l w
fv
: k
j
,
.41
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.
A/ TESTS WERE COMPLETED ON:
NAME print)
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBERIoptionall:
o , 5~foo 3 7 7~tG
CST SIGN RE: ,
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER - J
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
'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.
C
PLOT PLAN
PRO ECT c~v h/ ,&,4+ &ADDRESS
)OCh/4,51e-) 1/4/S ,~1/T j,9N/R /7 W TOWN n 7/i', kCOUNTY
MPRS Byron Bird Jr. 3318 DATE - 2-- 15;~_
BEDROOM? CLASS PERC / CONVENTIONAL/ IN-GROUN RESSURE
CONVENTr6NAL LIFT MOUND_ HOLDING TANK
SEPTIC TANK SIZE ~c LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE _BED SIZE 9 .3T~
Benchmark V.R.P. Assume Elevation 1
Location of Benchmark e o o ~r ~i4C
* H.R.P.
D Borehole Q) Well Scale = Feet '
0 Perc Hole ;f f System Elevation ~t 5K
C/ TYPAR COVERING
12" 3' 4 g' (D 3' 3' 0 3'
1 Sewer Rock
6" 12' 18,
P
~Co/y
V~
~OG 4boy4 lam'
G lay l~
.fib 30 ~
3 . -V