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HomeMy WebLinkAbout022-1028-60-000 ~ a 00 4 0 c c ro r,. a n o n m I Q N N N O O. CO N 0 ry C 3 ro N Z 0 N_ N O 2 O N 0 N y H y a D o 3 m c E O co and E_ E > N 5%C ro C ''. O C p c ..: CO �-m Q C E .O O C N ro d N 0 Z 0 a3oo E a LL c O U m N@ C "U C =O o U N o � -2E- -' E <L d m ro N V ro M CO Z C O Z >� L O co > '. a m !- Z N o I a> O 2 :!t ro e' N N Z N N M C @ 7 N N N N C •AV ,0 L O O 0QQ O Z Z y N E N T1 E a '« o LO LO y E O F- o O O �•l M G d O) N N a •�I Z F- F- F- IL = 0 0 3 3 3 Z 0 0 '•' X000 •►� @ aaa IL 3 0 N 0) rn a rn rn o Z ao LO �l m o _ o a) o M E N S � 01 •C N O 733 IOWA _ _ p d Q Z ;n ro *�► o d C c o Ol O o 0 H e 0 0 CO CQ ~ '00 0 O 0 O (Z) IL o m c c � rn o 0 O � U O ._ C _ � O �-• N N O '0 O 00 C6 r U c ro Q) `° N ,_ I U CO N Z Z .0 r CD L: ap CO o N N • 7a N O C O N co C? N EO EO U c' i, o Y �'.. o Z H F- 0 � *�► y E Z, E `L a; ik o. y a •c� 'a m .2 ! 4, a a `Fv E v o n o 3 y o t I DEPARTMENT OF REPORT ON SOIL B SAFETY& BUILDINGS INDUSTRY, BORINGS AND DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX HUMAN RELATIONS MADISON,WI 533707 707 (ILHR 83.09(1) &Chapter 145) LOCATION: SECTION: TOWNSHIP/ UNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: NwV4 N w 1/ to /T z8 N/R�ItE `cc_t>u tv�e 4t.t COUNTY: WNER' UYER'S NAME: MAILING ADDRESS: ST- QAQZ V "QF_11_L1c 2 USE DATES OBSERVATIONS MADE Residence NO.BEDRMS.: COMMER IAL DESCRIPTION: (PROFILE DESCRIPTIONS:1PERCOLATION TESTS: Z IV, k. New ❑Re lace p RATING:S=Site suitable for system U=Site unsuitable for system owl—g 'Te DY TbP4 Ivt_MLSUk.► 01LJ — —� Ms ENTIONAL: MOUND: IN_ -GROUND-PrRREEtSSURE: SYSTEM-IN-Ft -11-ILDING TANK: RECOMMENDED SYSTEM:(optional) ®U ®S ❑U ❑S NU ❑S [✓y.0 ❑S ®U 'f'Iwxj% - �-11GN Gtzujx�wRT�R [under Percolation Tests are NOT required DESIGN RATE: I If an N p y portion of the tested area is in the I` ' ` n ` s. ILHR 83.09(5)(b),indicate: N\ Floodplain,indicate Floodplain elevation: V R PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-I"Abt�S CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH h8k OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 1 U-0' q�J.) ' t ►t? moTm 3.a' o.�' DEzGysillS;Z.3'8ns' ; oS'Yt3»cl-o. S '[. sAR B Is0IQL V"01 (Z L4.01 0.6' q I•Y' it ;o•S'13n V sl;♦•O'`'(8h c l R- k3Q"a y s.a' o.�' ►( ; -z..3 ' �, ; 1.0' LS82 -- --- Ll•S' wore s, W p. l' l( Z. q i0.7' S LS 82 rt ( (�( i 0,-/' L S 0 Q Al.-g ' N N01V� mo 1. o.�� if ; 1• S'Gysil ; )•b'R8r►D�Se: v 1Y B- `7 X4.Li gcj,g l IJti1v�c. me 4 3. 5' o•->'fl�6 S'/ !S'Z.g'BnSi/ •0.S,-1&nCl; o•L/LSB)e B- " 3 3' 100, b ' �Ory vut®TC$__Z. 1 ©• b' '( 1 1•S' B- � t No L C-h �3 o2.tti G �T r�ov S 1 TE • PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD3 PER INCH P_ Z X10 3Q 1) $ ) 31110 1 1/1 Z.-7 P- Z 24 1 10 30 \S) 16 151 6 1 3 Q 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. MI. L O` • S ( SYSTEM ELEVATION - _ mm ; 6,; � 1-��1.,i uu �1'u X�wo c e _ E , 4 e i!-UP1 '0100- . S 0 1 01='Tnl�� K3U d1ZK1eu_ e 1 Sw�.L-.' *e ST-1L eOtST ; �1 'T') l<3 i Iry- 7�tCc�tfyj ,.p I- iz or*� ra o ut�t1, ID3 3 bZ l!� awn �9 _ v - 14 1 ' 1 s a _ _ 154, z °; i G ,C0 E E - a BS 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. NAME (print): TESTS WERE COMPLETED ON: �tRT)—?UIZ L. ADDRESS: �ZDU Jr u $ u ZZ CERTIFICATION NUMBER: PHONE NUMBER(optional): EtiL w0>z w S p S�(� 7iS-4LS—otby CST SIGNA DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) —OVER — INSTRUCTIONS FOR COMPLETING FORM -1,lb `31) - 6395 i; , 4e,,rorj: -wit �n,,,,k ��,ofnplele and 2, 'Fh, use so'clion mtll,,t Clearly this i`,a or 3, MIAMIM-UNl t'KffObft Of be,,,-Jr00MS CF COn)MeMic,O Isf; P;Iir)nk?f-l; 4, l,f l i t 1)e vV r 0 P s Sr" �"e �t,)m, 1,�,"�, ,,, , , A S? C;. S U I T J�,8 K LY P OTHER RULED OUT BASi-0, ON SOIL 6, PLEASF vi iting prof 10 d^ 7. =VIAKE A 1...€'E I B 1-1 A 1' s1h k 0t ' s I b:�X�- � Cw�p,e— ah apps op6a,"Io, s dM", T)0 Cip i,,1 w4J your co,0 A rC QUH,8d. ALL SOW-, ILED 'V I H i LOCAL AJTPORITY VVATHIN 30 DAYS OF COMPLET;O!"L A13011 EV I PTO FOR C'ERTIFIED 'SDIL of 'Textures svn !,wi- RR Cob 10 w,iJer 3"1 Lb j S a H GVV (v- rneu 's rine saml Blop L b 5' t Loam SWy Clay if, S,x B VRP TO THE OWNER: This soil test report is the first step in securing a sanitary peri-nil.- I he c €< ,C) D,spartfnent may request verification of this soil test in the field prior to permit o plans for the private sewage system and a permit applicalion 11-nlst be submitted uo in order to obtain a permit. The sanitary permit must be obtained and ter sted )r construction. EPAP ,-=NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INf,t;STRY _____ _ DIVISION LABOR AND PERCOLATION TESTS (115) P.O. WI 53907 HUMAN RELATIONS MADISON (ILHR 83.09(1) & Chapter 145) (LOCATION SECTION: TUNICIPALITY: LOT NO.:BLK. NO SUBDIVISION NAME: �/ �/ so /Tzg N/R � -E (or �u N 10- - COUNTY: WNER' UYER'S NAME: MAILING ADDRESS: ITT- CZ,J 1X �oCZ��+� lf�ivE�L�CZ �Z t LsR 1-=,rtt,�s W I SYOZZ. USE DATES OBSERVATIONS MADE i NO.BEDRMS.: COMMERCIAL DESCRIPTION: IPROFILE DESCRIPTIONS:1PERCOLATION TESTS 1 y4Re;ijence Z f�• New ❑Replace ^�_ �— ¢ c�— ll UQ RATING: S=Site suitable for system U=Site unsuitable for system OKJ—S tT1= D`f —k­bY7 CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ❑S ®U ®S ❑U ❑S NU ❑S CCU -1 ❑S ®U - %rAtGH 6fZo-_w�wR`I R If Percolation Tests are NOT required DESIGN RATE: p� If any portion of the tested area is in the under s. ILHR 83.09(5)(6),indicate. N `\ Floodplain, indicate Floodplain elevation: I PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-rNGW4 CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH ft ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 1 4-O' G�. ) ' N-�E? rndr(3 3.Q' 0•�' V?-6ysi) 1S ;Z-3'Sh5 o•S``>j3nc1;o. S 'L S TaR B Z 3.0' ��'1 * ?JpIQL= wt OT @ H.O' 0 6' �t 1 Y' '� ;o•�'Bn � s l; ♦.O'"`'(8tt C- 1 3 s-0' fv-a• tvo"F_z y s.o' o.�' << ; z.a ' ; z.o' USSR �B �,; y.s' N• t� NLior.16� w�cTe s,y' p."�' is • Z. it ;0•7SILSt3R S 3.yN-A 3.y' o,b' << ; Z-(4 0.14' LS32 B- 4-t' N. Noty� mo 1. ) ' o•�'- �� --- 1.S;GySi I ; 1.b'RBr GDQSe S 1 ; S 1 B `J �1 y' �9•$ ' �n+�E. vvtc �+ 3. 5' o.�'fl�zG sil Ts z.S'B►tsil •o.S'`>%,�►tc1; o•�J'�5812 \C�0, b ` ( 1J0>vE wwT(2 Z• ) p, 6' i ! inn Ii.C__h`T,� N3(YziAj 61 �T ntQ S T� PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P_ )1 Z lUO 3Q5 11 � 3)1(, 1 If 8 -1-7 P_ Z -2 ►JD 30 16 )N6 1 3 Q P- 3 Z 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 lonC slo p L' 1O1• � ' � s 7e W1jRl4'C� S1 � o`. E. SYSTEM ELEVATION c f snb\) lam*-I- E1-1D0 wooD t u t3 STt�.k E ),.j / t°►TN - e.Zmp > _ Q►"1i#Z - Lt 1DI•�` OK? 1KY-_Z'z,.M0 N 7 sZ L�GR`1-t� Do S._ ._ . S' rzzar1 w,ou� . Soo' E• or `Cte NW �4Riv ftT l-bNs r ____ ___ __- - N ti as i O,_ OtiluLa t3 i�w 2 zo V .�t o. 2 I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with thR.0 6dures and methods specified in the Wisconsin A:lmin.strative Code,and that the data recorded and the location of the costs are correct to the best of my knowledge and belief., NAME (Printl: ------ ----------= I7 EST tv=RE CbMPLETED ON: (ADDRESS 1`pV`� L/ a x ?Z CERTIFICATION NUMBER: PHONE NUMBER(optionall: L ----- —��—� _o?z—_ , W) S V 0 1 _ — S�� I S-4 Z S-o16 y CST SIRE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-8395 (R. 10/83) —OVER — L CtPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LABOR&''HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 N1&,,NW4, Sec. 10 ,T28—R18W F-1 CONVENTIONAL El ALTERNATIVE Sate PIn I D.Number: Town of Kinnickinnic ❑Holding Tank El In-Ground Pressure ❑Mound STH 65 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Gordon Mueller ( b BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV. Name of Plumber MP/MPRSW No. County. Sanrtary Permit Number Thomas SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO DYES ❑NO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WE LL ButLDING. VENT TO FRESH ALARM FEET FROM LINE. AIR INLET. DYES ONO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY JPUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ❑NO OYES ONO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING V NT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH IDIAME TER 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. q. DL1STR'P LENGTH NO.OF TEL PIPE SPACING. COVER JINSIDE DIA SPITS LIQUID BEDITRENCH TRENCHES. MATERIAL: PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEP IPF DIST R.PIPE DISTR.PIPE MATERIAL: NO DISTR. NUMBER OF PROPERTY WELL BUILDING V NT TO FRESH BELOWPIPES ABOVE COEV. NLET ELEV.END PIPES FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS 1-1 YES 1:1 NO DYES ONO DEPTH OVER TRENCHBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES El NO 1:1 YES ❑NO DYES _-ONO PRESSURIZED DISTRIBUTION SYSTEM: 'BED/TRENCH WIDTH. LENGTH TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE IMANIFOLD MATERIAL. NO DISTR DISTR.PIPE. DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV. DIA. ELEV.. PIPES. DIA.: DISTRIBUTION 111l. ATION, HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS 1:1 YES ONO DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING. FEET FROM uNE: DYES 0 N DYES 1:1 NO NEAREST System on Retain in county file for audit. Side. J. SIGNATURE: TITLE 'D 6710(R`oi/82) SANITARY PERMIT APPLICATION Ez d LHA In accord with ILHR 83.05,Wis.Adm.Code COUNT . .,..a.�.,.�,�,e,. -Nae - STATE SANITARY PERMI # –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ n��(eI 8%x 11 inches in size. Ch k e ision to pr sous application –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PRO RTY OW ER PROPERTY LOCATION Ile '/a N 1,v%a,S & T91, N, R & E(o PROP RT,Y OWNER'S MAILING ADDRESS LOT#� BLOCK CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME Wj S NUMBER eitity S ! 1 '5�26P rte (o(J ( ) ❑State Owned VILLAGE NEAREST ROAD 11. TYPE OF BUILDING: Check one CITY �11 ' OA //6 _Public 1 or 2 Fam.Dwelling#of bedrooms PA L AX E C.��— �O III. BUILDING USE: (If building type is public,check all that apply) 03a-1 &o- 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. ❑ 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 P Mound 30 ❑ Specify Type 41 El Holding Tank El Seepage Trench 22 In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION rb d-D < eet ,75 Feet CAPACITY VII. TANK Site INFORMATION in alions Total #of Manufacturer' Prefab. Fiber- Exper. New istin Gallons Tanks s Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Grp 4 L 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 is Signature:(No S mps) MP/MPRSW No.: Business Phone Number: '7Z 3C9,-3 a 9 Plumbers Add (Street,City,Sta ,Zip Code): #� s * s �a IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issping Agent Signature(No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial 40 Adverse Determination IV. X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: er SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumb 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 for monitoring groundwater, ground- water contamination investigations and establishment of standards. 1/88} f Z 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 �p Location of p operty �1/4 �.1/9, Section T o`0 N-R�W Township Mailing address Address of site 51 e Subdivision name Lot number Previous owner of property / -e pi Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _Yes No Is this property being developed for resale (spec house)? Yes No Volume ��a and Page Number as recorded with the Register of Deeds. ------------------------------------------------------ INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. --------------------------------7--------------------- 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 rec rded 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 construction of said system, and the same has bee" recorded in the Office of the County Register Deeds, as Document No. 7` Q S ) , Signature of Owner Signature of Co-Owner (If Applicable) ,/Z)-/� 0 Date o 3i ature Date of Signature s t M STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUM,OBER_ f FIRE NO. n ` CITY/STATE_ IL CU�V� F4 S ZIP PROPERTY LOCATION: 4b 1/4 JA2 _114 Section , T C/S� N, R �� W Town of �1 ��Ih 1(� , St. Croix County, Subdivision �--- Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED - 14 DATE v 9 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address j REPORT ON SOIL BORINGS_AND SAFETY & BUILDINGS olvlsloti ;i47 'STS' P.O. BOY, 7969 -ABOR AND PERCOLATION TESTS (115) MADISON.WI 53707 HIJMAN RELATIONS OLHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ UNICIPALITY LOT NO.:BLK.NOT SU_B DIV ISION NAME: Nw1/T io /TZgN/R �gE Ior NI?,3 1>.ekxJN Ic — COUNTY, WNER' UYER'S NAME: MAILING ADDRESS: RoU•T� Z �&T- c--o'I.x �0200� �'�vE�l_�cz w I SV o L ---- DATES OBSERVATIONS MADE USE I R F O��; LA 10N TESTS No,BEDRMS.: COMMERCIAL DESCRIPTION: oNew ❑Replace Q g p i ?Residence Z iV• �- �- S- 6 p I -�y i - c�t�.► -s tT'` ©Y �M I�.�L�LS Ow o�, �- 8-$ � RATING S° Site suitable for system U=Site unsuitable for system ----- (iNVEN`'i7NAl_ MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOnLLDIING TANK:RECOMMENDED SYSTEM:loptionall r r ®S ❑� ❑ ❑S �U D S ®U1 'f'lov�1� - �-1 tGN 6j2,U wRTe� SU_'-� - _ it pe,-p:„„-�r,'ests are NOT required — rES IGN RATE p ---� r Ir anV portion of the tested area is in the under s ILHR 83.09(5)(b),indicate N 1\ Fioodplain indicate Floodplain elevation: V [l - PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DE�Th+� NUMBER DEPTH ILL ELEVATION OBSERVED EST. TO BEDROCK IF OBSERVED (SEE ABBRV ON BACK) 1 U o' X19 1 N�x�ve 1nera 3.c' o �"DI�Gysil �5 ;2.3'Bnsil ,' o•S 'Y�3r,c/; o. 5 'LS � )2 �O'1 * IJp>JL VA C5 @ •O' 0 6' a I.y' �� ;p•$'Qn V s1;\.p'`'(Bn C- 1 3 S.o' rv.r�. F.�o►Jt3 > S•o-' �•��—``----- ---� -z..3 ' r, ; z.o' L.s8R g. :I. S' tJ- H IUpr�16i vnoT a 1•y' p. )' tt • 2.6' ii ;O.7'�I�1Cl;o.$ ' LSBR 1 —� 1--- _ S 3.14 N R . ' ° 6- ``_. ___ 2.L4 oI LSBR 4-'t N III rzvii e mo 1. 0.7' ri ►-S'GysiJ ; 1.6' SSr; SI ' B `� y y' 99 S ' -> fltcG sil TS z.g'Snsil •o.s'yc3ncl: o•y'LSB� ' >Jti�E VIA 3, S' o• °�-3.3' kC C. 6 ' �o*.�< wwTf? Z• I ' 6� '• ; 1.5' 4 0.3 ' �i ; 0-3 ' " B- _ \3O�Jti6 �T t''1OV S) I 1. PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERI D 1 PERIOD 2 P FE RI PER INCH z. ti.,o 3 0 P WSJ 16 116 1 3 O P- Z 2y TJD 30 P_ 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- zonta In(, .'enc�a! elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent SYSTEM ELEVATION ?'��� )i'o>=S — - - - - --- - - _-_. -- 31'1*_! - Ei'I00.0,0'1 1tlXZ 'wcoD �Te-I%Jt? LRTN I \- rov g 6 lb B t L�RST -r-s' tum j"r0UAA) Soo' E. 01= 'VII hat”) eoRK1es L ' I w sLLI. -M Bt NT l-c�AST O>= i'1't @ )l>LU ��v ILtic!fiy L � o r �¢ C. - a.✓--��,�, yz�N a I �o c u t. I s►TV 7 ^r r r f nd,•,c,gned, hereby certify that the snc tests reported on this form were made by me in accord with the pr,,cedures and methods specified in the Wisco nsin t4o'v, !;ative Code and that the data re,-orrif d and the location of the tests are correct to the i!es'of my knowlr_iyr and belief. �tNE "trntl ilES?SYdERE COI.z.',_ETEDON � I � 2�-�h 1•r, ,_ . l..v�G�lZ L1Z -- -- --- - 1 CcN?;FIC47 ".0 ' '.16ER. PHONE NU!Ip' :•nail. S-(4 S-o16 y - TC S SIGNATURE: DISTRIBUTION: Original and one copy to Lora Authority,P!operty Owne•and Sou Tester. DILtin SRD E395 (R. 10183) -OVER - Gondo , rnv e \ ko- 2 0 -T%L s N w R 8 Or lc�* 0 CZA c 9 lop IS 4 We-I1 7 25/ Sryv�� of f F V- Cor r of �e NL) IJ41f, M�l Scpl;-L 1',.-%< �) P"^p C•rAI�p(N 1 �jA OA S� D tr �„ ... - ,,, IJoJ& S+ckc 10 1. 0 0 n IXs ve✓( �'c2 S 8 9 40379Jge _ Of Straw, Marsh Hay, Or Synthetic Covering 1 Medium Sand Distribution Pipe Topsoil c g E D d .. Slope �.-`,`; •.,� ' Bed Of i«— 2 :2 Force Main Plowed Aggregate From Pump Layer D Z r Crogs,;:Section Of A Mound System Using E A Bed For The Absorption Area F .75 , G Signed. A Q Ft.� H I S / License Number: Ft.'a 3 I —L—LL Ft.' Date: 9 J Ft. Alternate Position K _ Ft. - of L 4aL Ft. , Force Main W 314 Ft. ; — L FJ 13 Observation Pipe sos h K -----------=- -- - - - w t _ '-------------- ---------------_ ____-----�. o � - Force Main —.._ ---"- - --------- From Pump Distribution Bed Of %" �- z — 2 2 Pipe ' I Aggregate Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area 4. 3 Page._ Of Perforated Pipe Detoll n End View PVC Pipe )Perforated End Cop �ot` �' d• Holes Located On Bottom, S Are Equally Spaced \ S PVC Force Main Q' PVC Manifold Pipe Distribution Alternate Position Of pipe Force Main Lost Hole Should Be Nest To End Cop End Cap Distribution Pipe Layout P I $ Ft. R S L� X 3(a Inches Y I e) Inches Signed: Hole Diameter [ Inch License Number: a 1 Lateral �_ Inches) Manifold 2 Inches Date: of Force Main _� Inches # of holes/pipe Invert Elevation of Laterals I03 Ft. . . , �\■■�e�■\�\eee■■■■■e■■®■ ►iii,■■■�■i■■■\■■■fie■■■■■■■■ 1 1 man MODEL 38.85 ■►•■■■■■■■��■■■■B dlid / r■■■■■■■■ ■■■■■■■■■■■7■■■■■iii■I�e■■■■■ ■eee■■■e►■■■■■\�■■■■■■■■e■