Loading...
HomeMy WebLinkAbout022-1026-95-200 03 ao � N a o w � Co O N co CD CL a°' ai N T ; cc i .0-2 CF o Its c (D a a`ni a Lo > I m O m`m LL o d w 3 m0 0) �0 CL Q cc � � M > v C U) E :: O � a � 0 I 0) H co z ! a m 0 o �zy/ v' c LL T v1 F- T CD z E v Cl) N O) •c a a� N •� d L O0 O N Q 0 N zmz N d C E N a d — °' E N_ w O V) rC rG rd Of O N N Q 0 3 3 3 ° o 0 Z N Z V • 0aaa CL c 3 co � `� U)� J U j rn rn } T T a� o 0 a N � O O ._ ? a m c CD a l Cl) 'p to G> O .O. r.+ O O` N C O E to N w F- •Op d 7 N O d O 00 O V (p C N VO) tOA t=6 C O C N(�O N cli 00 a C t19 N O O Z OD O N Z CO *0 N N L Y O cn E E L •O ' O O Y > T O Z U H H r2 fn a • 'l a d u 0a r`Iwv E 'c c °: r A ciao IloaiCi i � ' •.�� /C.Ci�ti��-cam' j// ��E �°`�' F/R-cf`.�5 �� �y.w,,,:...✓ �/ _ C ,s.w� L _ n/u' -sue /8 G �.own Cep :n l � q 0- y t �� ,t m 7r/g c • s 6,r' l "T-- �.J CERTIFIED SURVEY MAP LOCATED IN THE NW 1/4 OF THE SE 1/49 THE SW 1/4 OF THE NE 1/4, THE SE 1/4 OF THE NE 1/4 AND THE NE 1/4 OF THE SE 1/4 OF SEC. 9I'T28N9 R18W9 TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN. OWNED BY: WOODROW IVERSON RT. I ROBERTS, WI 54023 NI/4 CORNER OF SECTION 9, AND ORVAL IVERSON T28N, RIBW. (2"x 30" IRON 736 W. IOWA AVE. O PIPE SET). ST. PAUL, MN. 55117 O) nj On SET I"x 24" IRON PIPE WEIGHING 1.13 LOS. PER -SEE SHEET 2 OF 2 FOR DESCRIPTION- LINEAL FOOT. • - 1 IRON PIPE FOUND. Q:N SCALE 1" = 200' 0•W 0� 100' 200' 400' UNPLATTED LANDS SI°34'4$"E - 28.00 1.331 N87035'41"E 599.96 N89030'17"E 754,51' 17.39' O•C. 58 056757 PG.4 Q.C.D. VO,L.757 PCB;4'.T. • C1 NORTH LINE OF THE NW-SE NE COR. N W-SE Q� co LE—z SO.56'SI"w APPROVED : 3 288.62' t ( MAY 1 'L)" 937 � I �right-of-way Itn• a IL�� M W O_ y N 4.66' ST. Ck";X C. '.J�cTY N I Z 391.34' COMP12EHEW'SIVL ' .t::: NAi•<MWO 3 I it S89 03017"W 396.00 AND zoiflNc Cu+d.+nniEr' W z co 00 3 LOT :I PA RCEL RECORDED )11' 'ao O �J 24.97 ACRES ° Q• I , . . . . . . . . . . . . . . . . . . . I it Ln (1 ,087,633 SQ.FT.) i __1• ~ t 24,37 AC.TO R.O.W A W t L'OL::?!!E i ti , P:i, cyj C N (1,061 ,771 SO.FT.) I- . . . . . . . . . . . . . . . . . . . V to 1 20.55' Z W u7 1� 375.45 FILED O a N89°30'17"E 396.00 MAY131987 W > �4 .� 0 Amu of cofteu N C� r \. LOT 3 w ti 0 Z 2.85 ACRES �, W \ '•, ®� (124, 346 SQ.FT.) 12' z 1 2.55 AC. TO R.O.W. N89.53'00"E ' (111,113 S0.FT.) 9 141. 64' „: S89053'00"W 397.08' z \iL �d •0 68 A•9 ro: ° �. 1, 3�0. 35 �tu .. 1' shed tr a. �• u 2 \ .31 2 W. (n ��, Ng8 LO - (n y shed s n : _ �• It •• 10, house' h rn.: O PAR::FL REC. IN f to a LOT 2 AREA 0: '� J• \3 \• O� .�•.Q c�@, garage .W (2.22 ACRES A > ;° 4-!1 , c0. 566. Q • 96,884 SQ.FT) o. Z. W \ drive , h 2.02 AC.TOR.O.W, u:� W 7 •In Y �* ,1 Z 36.7617 f88,177 SO.FT.) O• � •< �- Z, to e�ec�s�a�vetNi 3 -V p 9/ \ S782 1893��.W �►�,m!` GO��,,'A '.O �1 4 V 00 N 's 0: ♦ JAMES M. • M o ''� \o, �: = WEBER O N 427. I 0' ^�' _ S- 1 804 _ z COULEE M SPRING VALLEY J WIS. ROAD M S89 053'00"W 444.11' W E �.•�•� wee SOUTH LINE OF THE NW-SE �•�,yo sU a�`� `�` S UNPLATTED• LANDS . ����ao®>re�°�� . . . . . . . . . NOTE: BEARING ARE REFERENCED TO JAMES M. WEBER S-1804 SI 14 CORNER OF SECTION 9, WEGERER,WEBER AND ASSOC. T28N, R18W, (COUNTY SURVEY THE N-S QUARTER LINE (ASSUMED MONUMENT FOUND). N 1.34'48"W.) DATED , Volume 7 Page 1815 SHEET I OF 2 THIS INSTRUMENT DRAFTED BY �• +•�AT�Spw. i p ut'f t- a-OD -41 4wvb W D p Form - STC - 104 a 2- °� 4''g vA L'T SANITARY SYSTEM REPORT 0ZZ �y p TOWNSHIP l � SEC. T N-4/0 W OWNER UC - `�--- ADDRESS �e e� � ST. CROIX COUNTY, WISCONSIN to Cr �sJ 4� SUBDIVISION LOT LOT SIZE r PLAN VIEW Distances and dimensions to meet requirements of II- HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM d .Yj f 110po ScPtr� r b 90 INDICATE NORTH ARROW V(e� ti BENCHMARK: Describe the vertical reference point used ,�D, to,") r, Elevation of vertical reference point: Proposed slope at site: y c Q SEPTIC TANK: Manufacturer: ll �S� /!(('� Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: 1,716 ^ Tank Outlet Elevation: < Number of feet from nearest Road.: Front,Side Rear, O Ia� feet From nearest property line ' Front &Side10Rear,O )aU t feet r _ Number of feet from: well ��D , building: *. (Include this information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type• Number of feet from nearest property line: Front, O Side, O Rear,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: r( r Width: Leng'Eh: Number of Lines:°� _ Area Built:f�� Fill depth to top of pipe: Number of feet from nearest property P y line: Front, Side, O Rear,Opt . 1767 7 ert Number of feet from well: . s d Number of feet from building:! Y . (Include distances on plot plan). SEEPAGE PIT r . 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: License Number: J 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 MADISON,WI 53707 State Plan I.D.Number: NW,,Si 4,S9,T28N-R18W Lq CONVENTIONAL El ALTERATIVE (If assigned) Town of KinnicKinnic ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound ER • L 53pa ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Woodrow M. Iverson Route 2 Box 75 Roberts WI 54023 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: Thomas A. Wang 3231 St. Croix 119429 SEPTIC TANK/HOLDING TANK: MANUFACTURER: ///''' LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER /a / � _ 1 O L/ �5 PROVIDED: PROVIDED: /y / ES ❑NO ❑YES CVO BEDDING: VE14T DIA. IVENTM TL.' HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE, AIR I L A ❑YES NO / ❑YES 0 NEAREST—► v�(� (� J 2 DOSING AMBER: MANUFAC RER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑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 WIDT: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID IF-5 TRENtr MAT IAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE I DISTR.PIPE MATERIAL: NO.D TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW IP�S� ABOVE OVER: ELEV.IN T: ELEV.END: '7 PIPES: FEET FROM LINE: AIR I L ��y rV,6 / 2 NEARESTM 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 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 I MANIFOLD MATERIAL: NO.DISTR.7 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—� Sketch System on Retain county file for audit. Reverse Side. SIGNATU TITLE: SBD-6710(R.06/88) Zoning Administrator i SANITARY PERMIT APPLICATION Cow 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 / )Qf revision a / 8%x 11 inches in size. El Check if to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. PROPERTY O NER PROPERTY LOCATION n ),,� �`5Q .1% /4,S � T�/d, N, R �E(o W PROPERTY OW R'S MAILINGeDDRESS LOT# BLOCK# c- STATE ZIP CODE NUMBER SUBDIVISION NAME O SjuI�UMBER � I D��r7�S S II. TYPE OF BUILDING: (Check one) CITY ❑State Owned VILLAGE NEAREST ROA ❑ � � e —] Public 01 or 2 Fam.Dwelling—#of bedrooms PA x ( a III. BUILDING USE: (If building type is public,check all that apply) i b2Z, I �2, I 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. ❑ New 2. N 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 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//s .ft.) (Min./inch) 9!f'_9 IFL ATION aU� o�/ �, o a d Feet 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 I Tanks Septic Tank or Holdina Tank !� WNS Lift Pump Tank/Siphon Chamber F 1�_. E I El- Vill. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name(Print): Plumbe ' nature:(No Stam ) MP/MP7w No.:� Business Phone Number: s� � P mber's Address(St t,City,State, i Code): P CV 1�r IX. COUNTY/DEPARTMENT 13SE ONLY </ Disap Surcharge Fee) Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Sta ps) •Approved ❑ Owner Given Initial /��U� Adverse rmin 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. 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-# 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 j completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property jl, )&) d r e)w ✓i7 . :72fel—io" Location of property 1/4 S j 1/4, Section 9 , T Of' N-R_Zk W Township khn%cklrin Q- Mailing address ' Address of site Subdivision nameF�`�`" Lot number CS V-, U 6 , Previous owner of property � l 101-2 ryc)" Total size of parcel �� a Date parcel was created �'� 0' / 9 C7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes N0 Volume and Page Number C59 7 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 warrant�j degd rec�3rded in the Office of the County Register of Deeds as Document No. "? - /IQ & ; 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. ) . Signature of-Ownef Signature of Co-Owner (If Applicable) /3/rs Date of Signature Date of Signature R P Sa, 4 .......... . 77'!T y} x sttN n f.'4 -y � 'aY .... ........................................... ....... .:? ..................................................... ... AC=NOWLXDGMNN: i' rz or WISCONSIN ........ ......................CONS4. - Pwoommy came before m this .......... ..ice�t .».».».................................9 19........ tw abom 86404 yr M .......................-............................. »....... ..,... ., ,� ,... ...».............................................».....»»»...a....a. +•................ .................. .............. ... ».....a. ' to r knows fie R vYa �T STC 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER �)ocJ r ()w Oe rsovg ROUTE/BOX NUMBER o FIRE NO. CITY/STATE � � j a ZIP PROPERTY LOCATION: W 1/4 ZSI�L 1/4, Section 7 , T_,)? N, R W, Town of htn r\ i -��t P-Nrl - , St. Croix County, Subdivision , Lot No. Uv� Improper use and maintenance of your septic system could result in its premature fail6re 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after Inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE �Z St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, bate, and Return to above address DEARTME'NT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY, LABOR AND PERCOLATION TESTS (115) MADISON W1 53707 HUMAN RELATIONS (ILHR 83.0911)& Chapter 145) LOCATION: SECTION: UNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: NVJ1/ Sk-1 9 /T28N/R /$E(o C.IrUI.) tClcrAJiu ) C r 2_ <-- I" \-),m%., -1 Pq 18 ) S COUNTY: MAI LING ADDRESS: V F-'u_1ELf V I eAj - CjL�QoLK w bu�tzuw v s tZ I v E_� 1=-O L.LS w t s o ii USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: A TS: Residence � IV , A• FON,- Replace RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) �s ❑u �s ❑u Ns ❑u os Zu as RU z f-) - tERMH S 'x»o, LoAj r. '1��IJ • \Z� CJ - Z, flT S'u 9 0' Lo1uc DESIGN RATE: If Percolation Tests are NOT required D If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: N ^� " Floodplain,indicate Floodplain elevation: '� • PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROU NDWATER-IRWW CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH Ot ELEVATION OBSERVED EST.HIGFTE—ST—TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- I S.8' IOZ.I � fvc 1� MdTc? S. 4 " a9'��a SPI s' ,o•� wA're ' Ss ; 1 •Z'�n s l ; b\r-!8vx Sj` Ts; ).Ll ' D1z8hL ;2-9 ` t�nSl ; B- Z S. $ q 9 $' 1-�t�l�►e hn�? (a S. 3 0.-� ' w 1t►TQ S 0. 7' DlzQ�nsj1TS; z. 6 ' $n 5.1) ; 1.9 ' 1:3» L ; B- 3 6. 0' )OZ-1.4 �orv� VA OT S•3' o.e- yv� Ire s B- B- B- PERCOLATION TESTS DEPTH , WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P_ \ Z V lJ 1J -1h QS 3/y 1)/f 6 31 4/ 0 P_ Z -Z V 1�v I�E 3 0 Sly 31 V 11!16 P- 3 IV 30 `S1I L 13))L 13/4 3 7 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. C!1 IUn• , �ftGE 1 S 1 v 1C�Lti1 3 t I 99.9 SYSTEM ELEVATION Z 99-y ' - i � IJ Ira •� o L.�CA4'f�11 � p1r t� 5 �o )CC�Vtk'n 14 G p Al 'C x - E A � E m � � _ — r E b - i r . ..... _ SCh�� 11i —f,b' TEl>�IiUNlr PE�ES7�tL- L937 S1:C 9 I,the undersigned, hereby certify that the oil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print TESTS WERE COMPLETED ON: ADDRESS: QpV�, I/ 'QQx '2.Z.(e CERTIFICATION NUMBER: PHONE NUMBER(optional): E I_LSLAJ 0 z S-)6 71S-42S- 0/6y CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHRSBD-6395(R. 10/83) –OVER – INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 6395 - To be a complete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations.Drawing scale is prefered.A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all apropriate boxes as to dates, names,addresses,flood plain data,percolation test exemption,if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10") BR — Bedrock cob — Cobble (3 - 10") SS — Standstone gr — Gravel (under 3") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well is — Fine Sand Bldg — Building Is— Loamy Sand — Greater Than 'sl — Loamy Sand — Less Than 'I — Loam Bn — Brown 'sil — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance.A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit.The sanitary permit must be obtained and posted prior to the start of any construction. C WOO�._UDGU .Tilers L Ile0 Ilt e bo CD feoL pp eh6- s rsn - �,