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HomeMy WebLinkAbout020-1210-40-000 O~ 6r3 a°io y ao 0.' ° I e I °o N ti I N i I C v I ' o I UO 0 0 c Z c Li c p o I y M I ~ w Z E I Z ~ € y CO~z am I o I O Z c. fn F r N 'D C f4 N N O N C Q y • d D (gip O O N Q O N Zco Z c V) z I 0 m 0 d c Q is E o N I T m m a 0 y c ',cocoa a~ a~ 0 0 Z • _ 000 CL CL N CL 7 O W N O> n J U D m co rn o !2 Z ~V N M 0 C O O tt7 C) a 'o m c n I c t4 N o Q in m O o c w O 9 coo E ch o O O N p O C Q. C a 0 e o m c y E_ o c, aN'o mLO E~ cC 75 0 ~i N o M N" Z L r • N (O 7 O tD p E U O O r 2 O Z U H d (n v € a v' a L: (L « o rr~~ A ~ IL 'i 0 U) ~1 Parcel 020-1210-40-000 03/21/2006 08:11 AM PAGE 1 OF 1 Alt. Parcel 16.29.19.1206 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner DAVID D JOHNSON O - JOHNSON, DAVID D 983 MCDONALD LN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 983 MCDONALD LN SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.290 Plat: 2282-PARK WAY ADDITION SEC 16 T29N R1 9W NW NE LOT 4 PARK WAY Block/Condo Bldg: LOT 4 ADDITION Tract(s): (Sec-Twn-Rng 401/4 1601/4) 16-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 862/552 2005 SUMMARY Bill Fair Market Value: Assessed with: 93028 217,500 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.290 51,200 170,600 221,800 NO 05 Totals for 2005: General Property 2.290 51,200 170,600 221,800 Woodland 0.000 0 0 Totals for 2004: General Property 2.290 35,200 126,000 161,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 126 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 r ~ y ` Form - S T C - 104 AS BUILT SANITARY SYSTEM' REPORT TOWNSHIP ~<Q SOn SEC. I (p_ T 2R N-R OWNER ADDRESS 4g- # ?,g z- ST. CROIX COUNTY, WISCONSIN 4apag W-j s-1 o SUBDIVISION &A. Uj LOT LOT SIZE Z,3g ArcL,, PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 c; SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM s I" for l~ VJ' Lo~~a~f but g . 7g ~iZ - - - - a ' g - eq- v - C a_) Sv `4 5 84. ~'f Z. 2. d ~I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: ~,(z _100.06' Proposed slope at site: SEPTIC TANK: Manufacturer:r S r✓ Liquid Capacity: / Q J O Number of rings used: Tank manhole cover elevation: v56: Tank Inlet Elevation: ~ k Outlet Elevation: 3- Number of feet from nearest Road: Front Side Q Rear, O feet 10 .From nearest property line Front 10 Side, Rear, O feet Number of feet from: well 79building: /5 / (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE f . p PUMP CHAMBER Manufacturer: Ilk 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: Cdrl~.m,Ll Trench:, T Width: Lenth: Z e, Number of Lines: 3 Area Built Fill depth to top of pipe: fez ~V Number of feet from nearest property line: Front, O Side, Rear,Oltt.47 i Number of feet from well: 9 7 Number of feet from building: 41 (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: 4 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: P Z- 3/84:mj o 0 N d + ~ a H oll l d ' All, J ! 6 L ~ , I s d . aJ H ~ d N ~ I%L ~S `~n •T 'so ll~ ` 1 A ®DEPARTMENT OFiNDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.&. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON -ys 16, 7 29, 19W State Plan I.D. Number: NA~, XNx (If assigned) I-1 CONVENTIONAL ❑ ALTERATIVE Town of Hudson Road ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Miller x 282 Hudson, WI 54016 - - q ! al) BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST RE . PT. ELEV.: Name of Plumber: MP/MPRSW I, County: Sanitary Permit Number: Doug Strohbeen 5432 St. Croix 119532 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET LEV.: WARNING LABEL LOCKNG COVER 79 9 RO DED PROVIDED: YES ❑ NO ❑ YES NO BEDDING: VENT IA.: EN MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM: FEET FROM I , l LIN AIR INLET, NO ❑ YES ❑ NO NEAREST ❑ YES ~ 4 DOSIN C AMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: 7PUMP/SIPH~?N MANUF CTUy7ER: WARNING LABEL LOCKING COVER R PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: U BER O PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN T FRO LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO AREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing RCE ENGTH: 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: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: / M RIAL: PIT DEPTH: DIMENSIONS Z3 3 ~ ~ 6 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY W L: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE OVER: V. INLET: EV) E PIPES: FEET FROM LINFFr7 AIR INLET: Z~ , / /r• 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: BED/TRENCH WIDTH: LENGTH: TRENCHES: LATERAL SPACING: [GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: 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 PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST -11 --i r Retain in coGrttq-file for audit. Sketch System on Reverse Side. SIG TITLE: SBD-6710 (R. 06/88) Zoning Administrator Thomas C. Nelson ' SANITARY PERMIT APPLICATION D1LHFR In accord with ILHR 83.05, Wis. Adm. Code couN STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / 8% x 11 inches in size. neck re slon t revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION h 55- S 16 Trin , N, R E o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 7i CITY, ST TE ZIP CODE PHONE NUMBER Su I S ON NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned E3 VILLAGE : ❑ Public W 1 or 2 Fam. Dwelling-## of bedrooms R ELTAX MBER ) III. BUILDING USE: (If building type is public, check all that apply) O Z p I Z, /0 . ~0 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 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. New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E1 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 Holding Tank 11 N Seepage Bed 21 El Mound 30 El Specify Type 41 ❑ pit Privy 12 Seepage Trench 22 11 In-Ground 42El 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.) (G Is/day/sq. ft.) (Min./inch) ELEVATION Lfs~ /S A !s C Z Feet T_57._5' Feet VII. TANK CAPACITY ° Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App I Tanks Tanks structed Septic Tank or Holdin Tank / A."al -se✓ R4 =F_1 Lift Pum Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber a Signature: (No mps) MP/MPRSW No : Business Phone Number: St-/ a-9-P\ I 3 ZV7) -3 Z- Plumber' Address (Street, City, State, Zip Code): e-4,13 f-Ij wto ~-c~ r 30, IX. COUNTY/DEPARTMENT USE ONLY Issu' g Agent Signature (No Stamps) J Disapproved S tary 7vrmit Fee (includes Groundwater a e ssue Approved ❑ Owner Given Initial Surcharge Fee) ff _ Adverse D ermin tion J 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: I. 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 fo? 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-<~,w Location of property 119 A4W -1/4, Section Township ~IfietSQ~~ Mailing address Address of site Subdivision name ! .l'a i Lot number Previous owner of property Ldts/act ,7~if Total size of parcel Z. 29 ~~.~✓S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)?-4-Yes No Volume JKD and Page Number 5-,Tf2 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. , and that I (We) presently own the proposed site for the sewage disposa system ystem.(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 duly recorded in the Office of tCounty Register of Deeds, as Document No.3Sg Signature of Owner Signature of Co-Owner (If Applicable) - aj~ -8'q Date of Signature Date of Signature go aalt ! i.w.........,...w .t.•a. •.NNW . «.iw.wi....... ...N............. old Yh varmub /e af■M L.Millez.,..11..a1ttaLt..pas~a .w....w... ~ ~.ll4S M' ».»N......».....N....... N..•MNNM..wNNNN...w~..M.wNw..w...wa...aw.w.w... N wNNww............ ..01 1 . • »ww .www.. w..wa. wawa k N.W.N.wwN. N.N........www..•....w•........ J NT..•...a.~..ww.V.N.... ..+.w.w.ww.w.......ww ............................ww.....wa..ww ee*~» ro l ..w «......aw... a..................».. .........................a.......... ..i.. a. • "d "we in N .Sswamcift N Ci00DtY . Not oreMlrsR Qwrler of t" Nortbwt Quarter of Seetiom 16. Towasbip 29 North. 1!`0101. at. Cs+oia stye Wiseomaia QCa01T Lots i tbroq* 49 inclu 've of; l ► tiled July 239 1M in Vol. wS". pop 1447. Doe. No..' 395024. eot3 to 09 Dao"mtiea of lrotoetivQ Oowaents dated February 13 1laS, s~oriad the Off"" of the. 10000for of Dwds an 1a 1983 In F.erm.ry is, Voi. , 706, saq Aoam..mc No vl` ,**Jftt to ,on-embuire ess@~ is of record for uN of the 66 foot reed Vast of ' 3 of tbs 0681 s ationed Certified Surrey Map. M*Jeat to tba`lartition Foaea 4araarat betwsa tbs State of Wisconsin ^ o= al N wwAm a sad 010107 Fora dated September 15. 19799 seeordsd ~ p006W 2a. 1979`1 Vol. 06010. pass 639. Doc. No. 36ol2a for tbs msinteaaaee of li between the aW k of Sa As of Seot3oa 9-29.19 cad 1W As of Nt.k of attoa ' 16,21-11. is A I* wansuft: f F t 1' et , K - ........................111..1 f/ ..........................43ZAL) NAr..N......... ' ~ • r~O~~+a . jlaiaa . ~ar3ya~~.G !1 q F~ .(SLAW f ts.,~,r.........(BEAL) ;t tf erri~....... Fora ~a ' •UTUXXVICATIOx AO=xow►LEaax>•xs ......................a..........................•....... STATa or I M11CONSIN eNtoRMnbi rife ........day oL.w .......w. ........1•...... g~'., CIfOIX ...................Ceoety. all. Pe "Nally came beton on this ...day of '•N ..............a.....................wN.............w.................... IYAS... tM above emned t ..lara adkla.Yss li..Y /uotd...... .................a.a..w..w a............................. arm. TtTL1e8 xl MMM UrATS DAf1 Or WI llar1Qlt ..R1A~IM.. ST~.N,[jl,(A Tj4 *.i. . 11MNSiN .F~fm n* (U look to "m lrt rf sown to be the I"eell wM =mew the + t THIS ausTeUwelvT WAS eu.rm w nR 1 t wk ice the came. . • ie . . C1co1x . . Gene mn be svdwatl mw or sawwledewf. Roth Nx Com Pumhl"le in Caonty. Wig. NtPIMfiMI mi we ad messum ) AL~'1 U_ 1p _ Mfi date- 1~Q•) ' •t. rw.... were w - - _ ..r.eNr Mr.M M tf.nA of, nrlMnl Mn.. tA.lr eTATi nAn M wtxCOMRIY ~I'L~ewh JASW 111wn~ Cn lur. MOllle M.. e. L.e STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 2-/y/ ROUTE/BOX NUMBER Z~'L FIRE NO. CITY/STATE h/u4esd." ZIP S`7400'((0 PROPERTY LOCATION: 114 I/Jr 1/4, Section JC,, T N, R J Town of t , St. Croix County, Subdivision ,C ttJaY , 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 ( k DATE a-~ 7 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 r (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION 'LABbR P.O. BO HUMAN` NDLATIONS PERCOLATION TESTS (115) MADISON W 7969 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/""";-r:~: OT NO.: BLK. NO.: S VISION NAME: 4N'/a f 6 Y (o fn U,/C Wty COUNTY: ` OWNER'S BUYER'S NAME: MAILING ADDRESS: / d/',Ort er w .100 a. SRel I n USE DATES OBSERVATIONS MADE NO.BEDRMS.: ICOMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLAT ON TESTS: Residence t New ❑ Replace I _ p_ p D~ /O p„ RATING: S= Site suitable for system U= Site unsuitable for system s rZS ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM- -FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) (,r4l ❑U xS ❑U ®S ❑U EIS ©U EIS ®U Cd f~' .o/ /I°'X3d If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: 411,1 Floodplain, indicate Floodplain elevation: l lA PR FI E DESCRIPTIONS BORING TOTALS ELEVATION DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- f S K,tP' A10 A1 e- 7. S` 7 7 g// o ti S 6? S s B- z 0' e_ 7 f',6' 24'//, . / A'm / S. 6 8h fit B-~ 74" fs I? axe.- 7,,C, 2. V 00 - Y' A-18 c 7 A I AA / S Q S pi- B_ PERCOLATION TESTS TEST DEPTH! WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER itidGFF1@8 AFTERSWELLING INTERVAL-MIN. PERIOD: PERIOD2 PERIOD 3 PER INCH P- .3' o C L3 P- L r.0' A10 y IG P_ • L 3 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 q1. S'"~~ t ~ [ i b 3 0~ l~ i f: kC 3 1 `32, c € 1 i. l re, f~ € o I© sfl- s s,~1 caf *vuod AZ IV MAU, h uerf k~-/ ,0~ef4 1, 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: PeAtm.-Ij_ Pe 16A4Lf_4aV /0 - .2 J__ x6p ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 121-i 31` P-1 CST SIG TU E: ~ P, LD DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ILHR-SBD-6395 (R. 02/82) - OVER - r 1 4 ` I A. INSTRUCTIONS FOR COMPLETING FORM 115 - SRS} - 5395 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; 1 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'HOL:DING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED--OUT BASED ON SOIL CONDITIONS; 6: PkEASE use abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LF :LE diagram a uurately locating your test locations. Drawing to scale is preferred. A SE irate sheet: y be,.uscd if i S. P... sure yor.r .-enchmark _ -_:t:cal elevation reference point are clearly shown, and are permanent; 9- Cc nplete all appropriate bo> > as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information 'Arch as file I * in, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and ice your ri, nt address and your certification number; 12. Make legible cots and dist..'Rute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL. AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIES SOIL TESTERS Soil Separates and Textures Othor Symbols st - S-° ; (oven 10") BR Bedrock coh Cobl (3 - 10") SS - Sandstone gr Gra,. (under 3") LS Limestone *s Sand HGW High Groundwater cs - Coarse 7 Pere - Percolation Rate wed s - Medium W VV-,I fs - Fine Sar : Bldg Fuilding Is - Loamy Sand > - sl ' idy Loam < I I L ;tm Bn - t : c ,,it *Sil - * Loani BI - Black Si S. 't Gy - Gray, ~Icl - Clay Loan Y - Yellow sci _ Sandy Clay Loann R - Red sic' Silty Clay Loam mot - Mottles Sandy Clay wI - lvith - Silty Clay ff f few, fine y _ cc comp no s tit corn Many, err r2i d - distint, f,> prornine,, HWL - High vva-.= soil text r sun fac ~Jd waste disc. u; BM - Benc VRP - Vertic 'oint ' I TO THE OWNED: eport is first step in seeurinc, - The county nt may request in the field pr: A r; :r> for the private a -lit application rnt. '.re apt-,0,~ .+.orily in order to 7 y t;ermil must be I 'd prior to t' V construction. 57a 4' Nori Z Q'Q.~ ~o%4f a`f '7~'~td AllU, C< e~sr!' b o r-L s /BT4 k ho~~ J v' ~~G S ( ,-75 ~a~1~a». c12._.' /NO/6: ~G f 6~ l~ GiGUr p ~p Uo 14 a3 r 8Z ~ r 1 r o 0 ~ 'J Q i,~, 20' 00 4,e_ xYfi` ~ I i l