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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Sam
TOWNSHIP
SEC. TN-R I W
ADDRESS Rai, #ZS �- ST. CROIX COUNTY, WISCONSIN
5;-,? A
Ei��l so w= syv�4�
SUBDIVISION -Ts-co LOT W LOT SIZE 3, /6 7 c� 5
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Sm�lo s t!.csyy� � KcJ Loi" #35
Id->f 35w E.
3
I '
qS I
90
� e i
Ioo o ys' Ye
qd J
s
�NcoJ.�a am
�3si✓
( A I
' Wall Dr i Y< 4ea V
so
B•M.Toa .NST -P ED. A+ s.w_ Iot( f oar
INDICATE NORTH ARROW
�nl Liar lama..
BENCHMARK: Describe the vertical reference point usedT-tdr WS' pqA S w e%'104-c
Elevation of vertical reference point: Ipp.a' Proposed slope at site:
SEPTIC TANK: Manufacturer: k�Ja; sar Liquid Capacity: 1000 !!5.0-1
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road.: Front, Side Rear, O feet
From nearest property line Front,OSide,o Rear,0 1U feet
Number of feet from: well 5 building: 'L L
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE -REVERSE SIDE —J
PUMP CHAMBER
,. Manufacturer: Liquid Capacity: "
J •
Pump Model: Pump/Siphon Manufacturer:
Pump Size
.v
Elevation of inlet: Bottom of tank elevation:
a
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 �S/YSTEM
Bed: � � Trench:
Width: floe Length: Number of Lines: Area Built:(' /?
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft .
Number of feet from well:
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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector•
Dated: Plumber on job 4�41
License Number: IL4 1' 3
3/84:mj
SAFETY&BUILDING
t DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR DIVISION
LABOR&HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
P.O.BOX 7969
State Plan I.D.Number:
MADISON WI 53707 (It assigned)
SW ,NL�4,Sec. 21 ,T29-R19 CONVENTIONAL ❑ ALTERATIVE
Town of Hudson Lot [:,5W ❑ Mound
P i �3_ L Holding Tank ❑ In-Ground Pressure NAME OHOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam er Box 282 Hudson WI 54016 REF PT.ELEV. CST REF.PT ELEV'
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: i
.v
i Sanitary Permit Number:
ame of Plumber: MP/MPRSW No.: County
D S rohbeen 5432 St. oix 135399
SEPTIC TANK/ 7. I Co =/O/./" '0. ass'
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV: TANK OUTLET WARNING LABEL LOCKING COVER
, PROVIDED: PROVIDED: 413,r,coo gS SS YES ❑NO ❑YES NO
ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
BEDDING: YEN*DIA.: VE+FT MATL.: HIGH WATE NUMBER OF LINE: � � AIR INLE
ALARM: FEET FROM
❑YES NO ❑YES NO NEAREST—►
DOSING CHAMBER: WARNING
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PROVIDED:LABEL LOCKING
ROVIDED:OVER
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
VNTTO
PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AIR NLET:RESH
GALLONS PER CYCLE: FEET FROM LINE:
(DIFFERENCE BETWEEN ❑YES ❑NO NEAREST�♦
PUMP ON AND OFF LENGTH: DIAMETER: MATERIALAND MARKING:
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.
CONVENTIONAL SYSTEM /6. = 96, bom o 5 S fie. INSIDE DIA.: #PITS: LIQUID
BED/TRENCH WIDTH: LE NO.OF DISTR.PIPE SPACING: MOATERIAL: DEPTH:
/ it TRENCHES: / PIT
DIMENSIONS g .36 (0
NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTyi PIPE MATERIAL: N DISTR. LINE: / , / AIR INLET: ,
BELOW PIPES: ABOVE OVER: ELEV.INLET: ELEV.END: ,/" p ��. e10 PIPES: FEET FROM �j
n 97 p//� 3 NEAREST-'� 9S�
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.
PERMANENT MARKERS: OBSERVATION WELLS;
SOIL COVER TEXTURE:
DYES ❑NO ❑YES ❑NO
MULCHED:
DEPTH OVER TRENCH/BED I DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED:
CENTER: EDGES
DYES ❑NO ❑YES ❑NO ❑YES 0 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:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: APPROVED PLANS
INFORMATION ❑YES ❑NO
❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST'►
lJ I h./�Q.k ��,Cic3�'���4°���C+'Y`� �•y.Q�'"'o_..:.s'.E c( 7 (.�.Ji;;�i-� /�'a f � � c..` �if' /' /
e ain in county file for audit.
Sketch System on SIGNAT RE: TITLE: r
Reverse Side. ,J
SBD-6710(R.06/88)
TOILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code f�
STATE SANITARY PERMIT#
–Attach complete plans(to the county copy only)for the system,on paper not less than El � '
8%X 11 inches in size. Ch revi n to pr vious 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
�� /a, S!::i
' N, R E(o W
PROPERTY OWNER'S MAILING ADDRESS LOT# OCK#
CITY,S E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C M NUMBER
t, S S 3 a 7e a"o( j i r 0
® NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑Stag wed 3 ❑ CITY / Lan
El Public 1 or 2 Fern.6welling–#of bedrooms PARCEL TAX. NUMBER(b)
III. BUILDING USE: (If building type is public,check all that apply) Z !/
1 Apt/Condo
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. M New 2. ❑ Replacement 3. ❑ 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 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. 17. EFINAL LEVATION
GRADE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 1ST (--7
415-0 ( /S Fl 5Z7L G 3 set 20'Feet
VII. TANK CAPACITY Prefab. Site Fiber- Exper.
in allons Total #Of Manufacturer's Name Concrete Con- Steel glass Plastic App
INFORMATION New istin Gallons Tanks structed
Tanks Tanks
Septic Tank or Holding Tank 1040 k�j F] I F
Lift Pump Tank/Siphon Chamber Lj
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:(N tamps) MP/MPRSW Ni3] B s Phone Number:
k ►� 141V zy7 z
Plumber;d Address(Street,City,State,Zip Code:
C k ✓k Z /
IX. COUNTY/DEPARTMENT USE ONLY
Lj Disapproved Sanitary Permit Fee(includes Groundwater Date ssue Issuing Agent Signature(No Stamps)
Surcharge Fee)
Approved ❑ Owner Given initial l ao
Adverse to min ti n
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 numbers) 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)
{ J a
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owners) of
the property being developed. Any inadequacies will only result in delays of
the permit Issuance. Should this development be intended for resale by
ownet/contractot,(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 -S t &I
Location of property zL 1/4 kke? /4, Section
Township -Bads o -,
Mailing add teas BeX
/�
Address of site Lo`' 1 3S o r�i ►' 4- (0.K m- Ja< N
subdivision name s Lg N�Q,vuo --
Lot number -T-
Previous owner of property V_; eQ, K%ga AA.,U.., <o�
Total size of parcel 2./(, 7 A--.
Date parcel was created 3 — Z Z— 9g
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for resale (spec house)?_ Yes N0
Volume O S and page Number q(aZ 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 ORAL 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
Nap shall also be required.
-------------------------------------------------------------------------------
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (out)
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. /4 3 S"1/ 1-7 • ; 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, lot the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. ti 3 s 41 17 ) .
5�� (0 )"
S gnatute of Owner gag Signature of Co-Owner (If Applicable)
II- t w_-,
Date of Signatute Date of Signature
•
000.1J0.1r•11 N0 WARRANTY DEED //11s sea a az•gal•zn 1410 an.r•nl..nl. uses
STATt: BAR OF WISCONSIN FORM 2-1982
435M jell;� REGISTER'S OFFICE
�•• ST. CROIX CO., WI
Recd for Record
Vlrl;lllls M. Hanson. a single woman
« 8:00 A M
1010.,•>. .111.1 I%.1mill. In Sam E. Miller. it single man
ftok w of DO*&
• 0.. .911 .n
lite (rll•lalne dr%ellbrd real acute in St. Croix
Walr u! Wascon!in:
Tait Parcel No: ... .. .... ...............
West Half (Wl,) of Lite %outhwest IZuarter (SWII.) 111 Sectlun
Twenty-ono (21), Township Twenty-nine (29) North, Range Nineteen (19)
West, St. Croix County, Wisconsin except that jlart South of the I.ublic
highway and except Lots 5, 6, 7, and 8 of Certified Survey Map n Vol. 6,
Page 1747, Doc. Nu. 419479.
That part of the West Half wo of the Northwest quarter (NW&) of Section
Twenty-one (21), Township Twenty-111110 (29) North, Range Nineteen (19) West,
St. Croix County, Wlsconsln lyl11l, South of Lite right of way of the
Chicago, St. Paul, Mlnneapolit. a11d Omaha Railway Company.
EEF
Thivi is not hnpll.lra.l proln•rly.
talk 11. still)
Far4l••intl b• warranlien: e8Sem•_Ilts of record and pro,-ective covenants and restrictions
of record, Lf any.
Sr
1411rd tlnx � ) dal of M ( (� 11088
1 a E A 1.l 1:A 1.1
Virginia M. Hanson
I EA1.1 INEAI.1
AUTHENTICATION
ACKNOWLEDUMENT
Signature(@) STATE OF WISCONSIN
County, a:•.:
authenticated this .... day of 19 1'rr•onall%. cattle lot-(ore nip this `�' ve day or
M A ,L t- . 11188 the alcove nanio%l
Vlrglivia M. 11annon
TITLE:: MFMnElt%TATF HAIL OF WISCONSIN
Il(not,
authorized by i 711..9», Wilt. Slab.) In fill. L11oun In hr Ihr prrrun uh.. rs.wuled the
fun•eoist• Iruntl•nt ant) s1*ikl.nn•1e.1j r tier »:11114.
T•1 1.1N6TRUM[HT WAS nRArT1.D nY V`
Lois•A. Murray, .11eywpod,, Carl b Murray �n 7
P.O. 8vx 229, Iludslrn, W1• . 54016 fkil( c. ..
.8001•• uMic P •�� 1'nunlc. Wi•.
fsirnab irv% #silly hr ntithenlirnled or arkn11n•Ir.1ge.l, Il,ah Me 1'•••11ai y./l U QII�e1�1an.•1/#.I if nnl. t•lalr 4•:1•fr'a�lio.l
ore toot nerrltltary.) dal ;,''. •ZY 1901 / .1
-Name*sir Mr«m•planing In any '81-m il, •1.....•.I 6 1.1.1.. 1. un.1 1 L w •6.•. V.
WARRANTT DI:►D STAIR, "An nr IMPACnK1 W
. •.
►'r111M rte 2-- 1• M..•...�n 1•.�1 1•Lr
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ° "' � �r
FIRE NO.
ROUTE/BOX NUMBER--fp)6 1
/-r�./
i.y Z I P
CITY/STATE
PROPERTY LOCATION: SvJ 1/4 X1/4, Section
Town of St. Croix County,
Subdivision �a-yobs �a" �''^" —'
Lot NO. 3 s--
nce of your septic syd :em could result in its premature
Improper use and maintena
s. Proper maintenance consists of pumping out the septic
failure to handle waste
tank every three years s. sooner, if needed, by a LICENSED SEPTIC TANK PUMPER-
tank
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 restive a grant wforin MAXIMUMi Of
$3000 of the cost of replacement of a failing sy ,,
prior to July 1, 1978. Stt)�atrow County accepted
ALL NEW p program n us
SYSTEMSagreetokeeptheir
1980, with the requirement
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning 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 ing condition than 1/3)fu after
Inspection and pumping (if necessary), septic
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
1/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 tedwandoreturnedatomthe St.Croixa County u Certification
Zoning office within
form must be comple
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
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
INDUSTRY, PERCOLATION BOX 7969
LABOR AND
HUMAN RELATIONS �"ERCOLATION TESTS 115) MADISON,WI 53707
(ILHR 83.09(1) & Chapter 145)
—SECTION: TOW / 1J :
LOCATION:sw 1/N w '/ z r /T'z4 N/R►4 41lor c�l�so►J 3Sw J��o Rs 4 Q 6/t'4
COUNTY: MAILINu ADDRESS:
�T C Q4►� <- t lLt~ 1 Pour Rk0<5y_ � U LSO ti W i
USE DATES OBSERVATIONS MADE NO.0 MS.: OMMERCIAL DESCRIPTION: C
Residence uN eNew ❑Replace I Nov r 19,0 Nov 4 �9V
saps 6k 4 S� &ICS - 1� ( 4- PILLOT
RATING:S-Site suitable for system U-Site unsuitable for system
S
ENTIONAL: MOUND-'❑U ING�S ❑U S-I❑UL ❑SGZU .RE^oNV�/uti SYSTEM:
rJh�llLopt �all
Q
DESIGN RATE: A/A
If Percolation Tests are NOT required. If any portion of the tested area is in the
under s.ILHR 83.09(5)(b),indicate: CL t4�,5 t Floodplain,indicate Floodplain elevation:
ISec 7-r PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH to ELEVATION .ON BACK.)
OBSERVED
B- l 2.7 S /o,.4Z NoMC > �.75� 4"6LC -1 zz`$ L ro'�n,��„C's�l� 59"$ate +�►S��te
B- Z 9.s� bl'S? l�aN� > 4 s� 4"t2/_-Q le-&4L /6���$eNC���G,r SS�B�•� IMS�'��
B- 9.9Z or. z 9'9Z 26,& cs ZC�Ba
B- 4 4Z /02.09 r4o c ? R 4
B- S io.z� roz.t�. ia.z� z3-ce<LIM 19"88R11iL
B-
c PERCOLATION'TESTS
TEST DEPTH , WATER IN HOLE TEST TIME W LEVEL-INCHES RATE MINUTES
NUMBER *ASSl>'S AFTER SWELLING INTERVAL-MIN. PER INCH
P. S.90 ro ,4o '>1. '>? >
P. 2 6.00 6 3 > >
P. 6.36 v > >Z <
P-
P_ V aTl Al �' �
P_
PLOT PLAN: Show Iota ions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevat on 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 `�sr�? f PSI Y _ �tb.��t � ,�w•r�
--+
I I '
m-c.�c'.S�oPC r less
_ _ . . _ IS v_ �- - r-- -
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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 print TESTS WERE COMPLETED ON:
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ADDR SS: , I CERTIF CATIO NUMBER: ONE NUMBERIoptional►:
U7 S c_w,446 S- I N1:0,,4 � skar 6 NaT IP X356-
CST SIGN E:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWN:R SGZ/!'I i "(OtUN sll i t�u tY.SD SEC. Z t T N-R I W
ADDRESS #Zg �- �' .�..v'� a,:i�J � , WISCONSIN a
J� ;L� 1
SUBDIVISION �dtGa-r.L���ak LOT -E LOT SIZE 3, 167 iLa-✓ 5
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
>� .Tm.�o(o s l.4 t H of" #3S
vl4irt�
Z f.e 10 i
Q12,
9 S g i
0 —
q6 J
y s
X175 6 � G i N h
w j r
w � A I
W..II Drl�r�4n1
� B.M.Tmp oF .NS� �'ED. A+ s.w. IotCoihci'
INDICATE-NORTH ARROW
Tdl r j a.. 14.11-
BENCHMARK: Describe the vertical reference point usedT.f f-W5? pj S W Gorytr
Elevation of vertical reference point: Proposed slo.pe at site:
SEPTIC TANK: Manufacturer: t jo 4; 5a l Liquid Capacity: 1000 Z o-1
Number of rings used: Tani: manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,Side,O Rear, O / feet
From nearest property line Front,0 Side,f?�Rear,O 9 feet
Number of feet from: well building: 7-3 _____
(Include this information of the bove plot plan) ( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUY11 CHAMBER
_.acturez: Iiquid Capacity:
=p Model: Pump/Sipc;un ;--,iiacturer: Pump Size
Elevation of inlet:
Bottom of tank elevation:
'L
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 plat.).
SOIL ABSORPTION SYSTEM
Bed: 6C.I. nj� Trench:
r �
''.dth:_�Q� Length: �b Number of Lines:�_ Area Built•6 y$
1 depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear,O Ft . 70
Number of feet from well:
i
Number of feet from building:
(Include distances on plot plan).
ZZPAGE PIT
Size: 9 Number of its:
P� Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
either a drop box o or distribution box O been used on any of the above soil
:,D-!btion erns? (Check one) .
:LDiNG TANK
Manufacturer: Capacity:
Number of rings used.: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front,
0 Side, o Rear, Ft.
a
k•
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Plumber on Sob: J
License Number:
/34:mj
i�
'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
S%D, 1�4 I, e c. 21 ,T 2 9-R19 State Plan I.D.Number
Town o f Hudson Q3T 3
CONVENTIONAL El ALTERATIVE (If assigned)X —
Prairia Lane Holding Tank El in-Ground Pressure ❑ Mou
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: 1 SPECTIO DATE:
Sam Miller Box 282 Hudson Wi 54016 �7
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: _REF. . LEV CST R F.PT. L V
Sanitary
Permit Number:
Name of Plum er: MP/M PR W No. ou nt Y
Doug Strohbeen 5432 St. Croix 135400
SEPTIC TANK/ :6. ",6' `>
MANUFACTURER: LIQUID CAPACITY: TANK INLET EL V.: TANK OUTLET ELEV.: ,WARNING LABEL LOCKING CO R ,
PROVIDED: PROVIDED: ,G,
oZ7 7 YES ❑NO ❑YES NO
BEDDING: VF4T DIA.: VEW MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T ESH
e,p d C•V• ALARM: FEET FROM LINE: / i AIR INLET:
❑YES NO C 6-S-6 ❑YES MINO NEAREST—► J �a a
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑YES ❑NO ❑YES ❑NO I ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY I WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST---00,
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 ors
WIDTH: LE H: NO.OF DISTR.PIPE SPACING: OVER INSIDE DIA.: #PITS: LIQUID
BED/TRENCH / TRENCHES: / MATERIAL: PIT— DEPTH:
DIMENSIONS ' 3(/ (0 T cy-
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.D STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
0 9619-BELOW PIPES: ABOVE VER: ELEV.INLET: ELEV.END: ,I a �(.� 40 PIPES: FEET FROM LINE: � �� � AIR INLET: /
VC. .3 NEAREST�� 9 dS- as
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 I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑YES ❑NO ❑YES ❑NO
FDEPTH R TRENC H/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
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:
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
r �b ` Ica•3 ` �Gc�. , �Gt�-I 5�a'c -r !'�' ti'�`z .,,
v v
in in county file for audit.
Sketch System on
Reverse Side. SIGNAT E: TITLE: /
SBD-6710(R.06/88)
SANITARY PERMIT APPLICATION
DILHR 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 /( ��
8%x 11 inches in size. ❑ Clreckif revision to Ious application
—See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
,/ ,�,r _ uJ t/a Lt '/aS z � Tz , N, R ��' E(?t)W
PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK#
?
CITY,St�TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
I. TYPE OF BUILDING: (Check one) CITY j NEAREST ROAD
I
El Owned � VILLAGE j U�„�, �� � ���
I
❑ Public Vi 1 or 2 Fam.Dwelling-#of bedrooms PARCEL N u R(b)
111. BUILDING USE: (If building type is public,check all that apply)
1 Apt/Condo
2 N 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
1V. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.1K] New 2. ❑ Replacement 3. ❑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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 [1 Holding Tank
12 n 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. PERO.RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION
7 Z_- ifs�O Feet X18. f Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
structed
Tanks 1 Tanks
Septic Tank or Holdina Tank lip 00 �:5�
Lift Pump Tank/Siphon 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): PI ber's Signature:(No mps) MP/MPRSW No.: Business Phone Number:
zy-, 3z 3
PlumberA Address(Street,City,State,Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee(includes Groundwater a e Issued Issuing Agent Signature(No Stamps)
�ry Surcharge Fee)
Approved ❑ Owner Given Initial i
tttt Averse t rmin tin 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
a
',. 11I&RUC'nONS
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,tany-new*
criteria in-the Wisconsin Administrative Code will 4e,applicable.,
3. All revisions to this permit must be approved by the permit issuing aputhority.,. ,
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399)to b%. _
submitted to the county prior to-installation.
5. Onsite sewage Systems must be properly main aineO. The septic-tank(s)-must be pumped by a ticensett-
pumper whenever necessary, usually svery 2 to 3"
ears.
8. - If you have questions concerrttnp:your ortsiteaewaU6 system,.contact your local code administrator or the -
State of Wisconsin, Safety & ��611dings;Division,60E)gW3815.
To be complete and accurate this sanitary permit appNcati_ n must Include...'
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(*of
where the system is to be installed. _:f
II. Type of building being served:-Check only�one and eornplete##of bedrooms if 1 or 2 Family Dwelling
111. Building use.if building type is Public, check all:appropriate boxes that apply.
IV. -Type of permit. Check only one,in line A. Co_r Iete line$if permit is for tank replacement, reconnection;or
repair.
_ .V. Type of system. Check appropriate box depending on system type.
` VL Absorption system-Informgtl6n: Provide all irifnrMation requested in##1-7. -=
VII. Tank information. Fill in the capacity of every new andlor existing tank,list the total gallons, number of `
tanks and manufacturer's name. Indicate prefab brslte?constructed and tank material:Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approvat only if tanks received
experimental product approval,(rom DILHR. -
Vlll. Responsibility,statement. Instal ling°pIumber is to••fili in name, license number with appropriate prefix e
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'dounty.Ti'W
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 seritice
streams and lakes; pump or siphon tanks; distribution boxes; solf absorption systems,,replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifidations for pumps and controb;-dose volume; elevation'differences,friction loss;,.pdrnp '
performance curve; pump model and pump` bari6fgeturer;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. -'
GROUNDNiAff ilf OURCHARGE
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 are4mec( fo :monitoring groundwater, ground-
water contamination investigations,and establishment of standirds: ~' `
_ « tali
1
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 6;t= /1- Z,' //-
Location of property S,161 1/4 /4, Section
Township
Mailing address &0 Zs�z-
/�
Address of site Lv"rxr 3S i r :
Subdivision name a-co(o s
Lot numbers z-
Previous owner of property V; eC4', ',a $A. yaN <o .
Total size of parcel -/g 7
Date parcel was created 3 - z-Z - B8
Are all corners and lot lines identifiable? _Yes _�10
Is this property being developed for resale (spec house)? _Yes No
Volume Z!2 T- and Page Number 4/&-z- 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 SBAL 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.
---------------------------------------------------------7---------------------
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (out)
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. 4463 S-v l-7 - ; 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 duly recorded in the Office
of the County Register of Deeds, as Document No. y 3 sy /7 1 .
Signature of Owner Signature of Co-owner (If Applicable)
Date of Signature — Date of Signature
n(l(7.I)1`61r►II NO WARRANTY DEED 1111! fe11 t atlLfolaO still alL/.qnN.. U.1•
STATE: IIAIt OF WISCONSIN FORM 2-1982
43;417 `.. Q j�risc REGISTER'S OFFICE
ST. CROIX Co., WI
Vlrglttla M. Hanson, a single woman Recd for Record
MA a 12 '095
« 8:00 A0�M
:ual w.Iraal.. 111 Sam E. Miller. a single mall
the fellow•Ine J"ve shed real estate in St. Cro 1 x l.nl.al,
St:/te o! Wiscowin:
Tax Parrel No: ... .. .... _..............
West Half (WIj) of the Southwest Quarter (SWII,) 111 Section
Twenty-one (ll), Township Twenty-nine (29) North, Range Nineteen (19)
West, St. Croix County, Wisconsin except that jlart South of the public
highway and except Lots S, 6, 1, and 8 of Certified Survey Map n Vol. 6,
Page 1747, Doc. No. 419479.
That part of the West Nair (W!g) of Lite Northwest Quarter (NWIZ) of Section
Twenty-one (21), Townshlp Twenty-nine (29) Nurtll, Range Nineteen (19) West,
St. Crnix County, Wlsconstn lying South of the right of way of the
i
Chicapo, St. Paul, Mlnneapoli:. and Ihnaha Railway Compativ.
i
•('KpN SF's h� O
$4�•--
�F
This is not hnnw%teaJ prl.plrh:.
tak I is sud
F:seel••ino t.• w•arrantien: easem•ants of record and protective covenants and restrictlotis
of record, if any.
Ihlled ells d:l) of M n1 ♦( 1!1 88
•-t/ I S t:A 1.1
Virginia M. Hanson
. IS1::\1.► I�EAI.1
AUTHENTICATION ACKNOWLEDUMENT
Signature(s) . ..... STATE: OF WISCONSIN
Countoi- o;,
es.
authenticated this .... day of 1!1 1'or�onallc rnnle before foie this 'd dad of
m }`
IJ $$ the :d111ec naed .
Vlrtilnla M. Ilanson
a
TITLE:: MEMREIt STATE: BAR OF WISCONSIN
I If Prof.
authorized by 5 06.06, Who. St.st.a.l
to rnr Looeo to he the per;on who rserutcd ILe
fon•eoin tnnnent :uul :Ii'kuoRled�e the sale e.
T•1 i INSTRUMENT WAS DRAFTED nY V:
Lols•A. Murray, .Ileywpod.. Carl S Murray 7,C'•,'�
P.U. hox 229. Iludslln, W1... 54016 "�• y f l(,,
ISieontures cony he Authenticated or arkn•.lrlydue,l. Ilolh Mo 1'•.•uai� v.n y.•�1�1an/•rl►.i If Prof. plate e•ce rali...I
fore not neeesaary.) dal•• . . •�� l0� .1
-Names of p.rv.m riming in •nr r.e..il, •L..•.'•I 1« 1.1. ... 1. ..1••1 I •,« q,... 1.. .
WARRANTT DI:?D 3TA'r P. PAR OF RI':I'/l\••V Vl r••....•o I•i.l 1.19•
1'0IIM No 2-- 1... .. ..• •. w•.
6'
L.
e
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER SQ m IV-1,'124L
ROUTE/BOX NUMBER L2 fC Z FIRE NO. --
CITY/STATE /�4�so� fA) ZIP r'101�
PROPERTY LOCATION: aJ 1/4 X1/4, Section �' / , T 2 9 N, R /
Town of St. Croix County,
Subdivision Lot No. 3s�
Improper use and maint enance of y our septic system could result in its premature
P
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. �n ,
SIGNED Y �
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
I�
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON BOX I 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: N: TOWNSHIP/MUNIC4pAi.�.T-lt; OT NO.•BLK.NO.: SUSDIVISI N NAME:
5W 1/ NW 1/ Z /Tz9 N/R'9 11(o4 fludsory 3sE ��a<oasLaNAr��•
COUNTY: MAILING ADDRESS: )
�TCPOIy 'S+4M MILtXk �IPoGT f�PC)0K TeffJ�ok-h �YUTAsa+�
USE DATES OBSERVATIONS MADE
NO.B AL R TI N: OFIL DESCRIPTIONS: PERCOLATION TESTS:
Residence LA — New ❑Replace a/OJ ' /9$9 6v 4 � p
lu CJLny- 71.D SC1rc.s 1A PLL.L1_rryv �V
RATING:S-Site suitable for system U-Site unsuitable for system
ON L: MOUN D; IN- N N- LL OLDING TANK:RECOMMENDED SYSTEM:(optional)
03S DU 2S ❑U OS ❑U ❑U ❑S CdtiV�LN1IONAL a dd
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.ILHR 83.09(5)(b),indicate: (:fJQSS ' lFloodplain,indicate Floodplain elevation: IVA
PROFILE DESCRIPTIONS
BORING TOTAL P H TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTHZt ELEVATION OBSE AV ED TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- 6 o >QNl 24�$R�►CS,d6r ,r ��� r�LS
B- 7 /g" LLTS e-L 33� QN CS C, C N I'h5
B- ID 4.at> t6O'S5 A15 NC > 9.6$ 1 " Za"6ogn L eAry
B- g •9Z /60'91 40 tj Lr > &.91 A.81-0S IS 8Q�C5�C.tz o r a r1s
B- 9.17 IU0 4� ON1 > 9.1-7 $<<-n 0, lek JL /'t 8'e G G 56 $Q►,1ti1S
B-
PERCOLATIONTESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL—INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER1002 PERIOD 3 PER INCH
P. Sin oN£ 1 /01,60 3 Z 7 2 Z <
P- Z AO oaC 0/.SO 3 > 2 ? > 2 <
P- .00 N 106.'Co �' > > Z
P-
P• AS t C
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 ail t orings and the direction and percent
of land slope.
SYSTEM ELEVATION. 4S-sc�
- -
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i t I
- -
I
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V
I II L
TTT
qqOl
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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 ��°°rint • TESTS WERE COMPLETED ON:
NAME A01,11SIS4 leuscll 14pf 4 /91a9 A qq RES CERTIFICATION NUMBER: PHONE NUMBER(optional):
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DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
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