Loading...
HomeMy WebLinkAbout022-1097-70-000 \ o aCD I & . 7 � ) � § k \ c c/ $ g � 2 0 & § � 'm0 LL ) L 2 ) a § § 2p). CD 2 L w B p n \ \ } m n e z � § z � k k � k � I � { � ! � z \ \ 2 � � CL_ 22 ■ E § ] � � / L) � o o a 2 a , . § LO k k c E � ) k M � .. ' f a a a I � - \ o B ° 0 U) u § § § z § � c § § { � / k ƒ � � § { ■ » � § o \ { c 2 $ / is % 06 § § f ) ] « \ z _ n 2 e z § § ƒ \ f o z f k ° # k I � �/ � k / \ . c $ J a DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABO 7&HUMAN RELATIONS DIVISION P.O.BADX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: NA4,SO4-,S33,T28N-R18W CONVENTIONAL ❑ ALTERATIVE (If assigned) Town. of Kinnickinnic ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound P MIT HOLDER ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Ken Lee Route 1, Box 168, River Falls, vii 54022 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 Thamas A. Wang 3231 St. Croix 119474 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: 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---1111- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER 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. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: 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: iAREST MBER OF PROPERTY WELL: BUILDING: COMMENTS: ET FROM LINE: ❑YES ❑NO ❑YES ❑NO Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710(R.06/88) Zoning Administrator {�, SANITARY PERMIT APPLICATION ( I 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 11901V 8%X 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PR P RTY OWN FR PROPERTY LOCATION Al e e 4 /4 Z:;/4, S 33 T N, R e- E(o PROPEF�,TY W(JER'S MAILING A D LOT# BLOCK# 76 ITY,S``T�`A--TE , ZIP CODE PHONE NUMBER SUBDIVISION 1 K E ORCSM NUMBER s �1 a a 2 a d d`' II. TYPE OF BUILDING: (Check one r CITY PNEA�711)❑State Owned ❑ VILLAGE❑ Public R11 or 2 Fam.Dwelling-#of bedrooms— PA E TAX NUMBER ) III. BUILDING USE: (If building type is public,check all that apply) 1 ❑ Apt/Condo (J / 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground � 13 ❑ Seepage Pit Pressure 43 ® Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 12.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 Feet Feet VII. TANK CAPACITY Site in oallons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Se tic Tank or Holding Tank 1060 Lift Pump Tank/Siphon Chamber I -L+ I F 71 10 F1 Vlll. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe 's Name(Print): PI 9%CA Signature:(No S ps) MP/MPRSW No.: Business Phone Number: a� 3�� 1 Plumber's Address(Street pity,State, ip Code): - IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent Signature(No tamps) 14 Approved ❑ Owner Given Initial %///, . Surcharge Fee) Adverse De rmin tin '1 �IIJ O r 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 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 1 . 1/88 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -^z- - - - - Owner of Property Location of Property ��14 S , Section , T N-R� W � �., Township j y, h �V I C Mailing Address I� I 600Z !' t0� � ells ltd ' � a Address of Site Subdivision Name Lot Number Previous Owner of Property �a V e b'r e 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 �'[ 3 and Page Number �-3 �-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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PRCPFRTV OWNER CERTIFICATION I (We) ceAti,by that att statements on this bonm aAe t.ue to the best ob my (oun) knowledge; that I (we) am (are) the owner(s6) ob the pnopenty denscA bed in this inbohmation bo tm, by v.vr tue o 5 a waA&avtt dee onded in the C 46ice o6 the County Register o4 Deed ass Document No. 2) C, ; and that I (We) pnes ent-ty own the ptopobed site ban the .6ewage dispops (on I (we) have obtained an easement, to nun with the above descAibed pnopehty, bon the constnuc ion ob said ,system, and the dame h be y tecmded in the Cbbtice ob the County Regtisten ob Deeds, as D nt No. ) . 4fGNATURi)OF0110WNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED F: ,. �( ".«nw.w..-.a+.w.P•.s,+.Mq.+.+TrM - Y.�IP+'� PW 141�µ l w- MM' 4l`tip Soilthtwot. (rtuu ter of the $011 A*&A Tuts M ' Qwu"t of the S mAbsest (4u"ur x. oit for a 5 ,el in t1w Northeast c +er tair S *40 435 feet of t FA*t 5w feet of redid NO* 33, ?chip 28 North, Ramp 18 imst. y " :wr,4 dll aad o4agular the bareditsaeats and appwteaeaces tbereusto beleaelpt v in&AV ' � • Bj.AitL ltttr9 asi6b is tae siiaple sad bee and Clow of amuabrawso except _ this- # (W >x F� ,...� .__ Mr at � E f Title: Metier State Bar "f wt Authorised osier Sec. '06 OG Yax- tae„ thin &W x4 Y W ±e..-� 1.4a ettK004 tlF!-t and sclyno. a � x . j g STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER y( ROUTE/BOX NUMBER_ '� � tow l © Q FIRE NO. �— CITY/STATE__ �` Y` GAL/S �/� [ ZIP �16 PROPERTY LOCATION: &L1/4 1/4, Section , T°e' N R �d" W, , own of /9h l 1111'1 , St. Crq,ix County, division , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance gnsists of pumping out the septic tank every three years or sooner, if needed, �ly 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 Wing Off' hin 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 r boo ' 6Y A taboo �ad Fri 1 • f i -_._ - { I ST. CROIX COUNTY WISCONSIN 4 ZONING OFFICE ST.CROIX COUNTY COURTHOUSE r�P 911 FOURTH STREET • HUDSON,WI 54016 - - - - (715)386-4680 June 27, 1989 Division of Safety and Buildings Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation of the Ken Lee property located in the NW 1/4 of the SW 1/4 of Section 33 , T28N-R18W, Town of Kinnickinnic, St. Croix County, revealed soils at a depth of 1.25 feet, below which high groundwater was noted. This site should be suitable for a mound system. Should you have any questions regarding this subject, please feel free to contact this office. Sincerely, Thomas C. Nelson Zoning Administrator TCN:rms DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS' INDUSTRY, DIVISION '- LABOR P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (1-163.090) &Chapter 145.045) LOCATION:/�("'�}� SECTION: D��{ S M 71CIP�LITY: OT NO.:BLK.NO.: SUBDIVISION NAME:(oo / C COUNTY: OWN BUYER'S NAME: MAILING DRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMEFI IAL DESCRIPTION: PROFI DNS: EST S: Residence New ®Replace ? 9 RATING:S=Site suitable for system U=Site unsuitable for system J ONVENTIONAL: MOUND: IN-GROUND Mu"]SYSTEM-IN-FILLHOLDING TANK:RECD ENDED SYSTEM:(optional) OS ©U ©S EA OS ❑S fRU I 0S DU If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain, indicate Floodplain elevation: ttnAs I& PRO ILE DESCRIPTIONS BORING OTAL P H T R UND ATER4"errES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH lid, ELEVATION OBS RVED E H TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) o.c, A16NE 113 W-SqLej Jar 61A si"'Ne%xr vo ' B r44fi B- ' ,w (rQ1101Mt9 rt .13 81 I66G sf'c Btk str 6! S trite fare BRIA sf B- A 61g. 4105 ra5faftoti f b/k Sit-wet,ire B- 3 ,�G lt�l.S' , a5' Blsi w suban �ar l� s�ru�fule,?,00 in B- e- w rusI mops o 14e- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I S AFTERSWELLING INTERVAL-MIN. p 10DI PERIOD2 PEFJ INCH P- / hoo 0 3 a 714 f/ P ! as O 30 9 P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION e et-Ty f IcP ' �. a-7 �__ . - - - - 1111�1)� � _ S 1e..el".IP ' ir xr .Q o . ! M_few s_ r �� ail 44 o001 1 i g_ __._ 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 p int - TESTS WERE OMPL TED ON: ADDR k CERTI ICA ON MBER: PHONE NUMBER optional); '7�� �rve� Fit / ,5. Sile0 JON CST TURE: Or'- / , DEPARTMENT OF REPORT ON SOIL BORINGS AND f. I 7/TY& BUILDINGS DIVISION INDUStTRY, ., LABOR ND PERCOLATION TESTS (115) 0. BOX 3707 HUNIAN RELATIONS �/ c.„ IAD1 WI 53707 (H63.090)&Chapter 145.045) �'' LOCATION: SECTION: TOWNSHIP/MHidtt°tPf�ti�Y: LOT NO.:BL — .: S JI� yOP�kJAME'; W-Se1/ 1/4 3� /TAN R IeE c ) kINK-1LCtcllaxi (C - n' COUNTY: OWNER' BUYER'S AME: MAILING ADDRESS: V S- (Z.54& X 1 L c' 1 YV0 USE DATES OBSE NO.BEDRMS.: COMMERCIAL DESCRIPTION: =E]Replace PROFILE DESC LATION TESTS: Residence A New _ Z�/_ g S N. A — RATING:S=Site suitable for system U=Site unsuitable for systemv ✓�2��� y U ' nL � I� CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDEDSYSTEM:(option ❑SIZU ❑SM ❑$ ®U ❑SA ❑S ©U s - (a -�1,L1G �it►.1R DoT [ALA-Owl=D 5'tS �R C,�vr.NT4 o�DlNhn,cEr If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the Na /� under s.H63.09(5)(b),indicate: ./a• Floodplain,indicate Floodplain elevation: Na __ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INC+WrS CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTHjfd-ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) ► Z.�' gz,o ' Doti` *nCT ® \.z,' o•y'Dk6yB,silr3� 1.2'GYBn sil ; �'o' G�rcl B- -Z Z .2' 2114. it 3' �t l.l' '� J, 0.8' Il 3 Z. �.' $9.S ' �t h-,o�-.Q 0,9' 0.3' cr X0,1' �� � l• l' " _ ►M.oT 4L L. I ' o, h' C" 9' 11 S O•-1' II 3 B- Co Z• s' $3.0' �� for Ga �.y ' 6' �� ; 1 ` o' G 1.5 , o. 6' ,� I.p' �I ; 1-3' Gyp's 8�•S' , S' sib - 9 z.o' 80.0' ,� tixe.T e I.p ' o,S' ; �- Gy B= 10 Z. Z' _1`f•6 w4uT (9 1. 3 ' C.-7 '� 0 9� e,• S0 • o. 6 ' G 69. 0' r a L.0' o. 6' �, ; 1.4 Gy Si/ B- �2 - a� 8`4-0' I.�tb"s rnc,T@ I•V ' c'. W ', t•3 ' G78. Si) ' o• 1 ' G ShC 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- P- 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- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. � SYSTEM ELEVATION N ' -'-- � i S 1 i7 i.. .._�-..m.,..i.....M.. - �.. e... ... v......,�_ P—......,.. ,,... t TN _ _.. - ' -'A i — 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: ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional): 12T Qvc Z-Z_L S_)11 -)t S-U 16 y CST SIGNATU DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —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; 1 MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacement system; 5. Complete the suitability rating boxes, A SITE IS SUITABLE FOR A 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 to scale is preferred. A separate sheet may be used if desired; 3. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0, Cornplete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test.exemp- tion, 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 your 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 Sail Separates and Textures Other Symbols st - Stone, (over 10") BR - Bedrock tole Cobble (3- 10") SS - Sandstone gi - Gravel (under 3") LS - Limestone Ix s - Saari HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate mec! s - Medium Sand kN t/Deli is Fine Sand Bldg - BUiiding Is Loal-ny Sand > - Greater Than sl Sandy Loam < -- Less Than 'I - Loam Bn -.- Brovvn 'sil - Silt Loarn BI Black si - Silt Gy - Gray "cl - Clay Loam Y -- Ye,I10v"" scl - Sandy Clay Loam R _ Red -_ sic;l - Silty Clay Loarn mot - Mottles s Sandy Clay w/ -- with sic - Silty Clay fff - fevv, dine, faint t C - Clay cc - comnion,coarse p Peat rrlm - Many, medium ni __ Mock d distinct p - prominent HWL - High water level, Six general soil textures surface water for liquid trraste disposal BM - Bench Mark VRP -- Vertical Reference Poirit TO THE OWNER: I;,is soil test report is the first slem irl securinzl a sanitary permit. The county o r the Departmtant 171,1Y rexcauest c;at;on of thi-I sol; test in the field prior 'M permit issuWrce. A complete set o° plans for the private ;cic; sysl_elm and a p�lrmii apphcatit)n muse he su"t rnitted to the appropriate local au[liurity iii or(,er to 3irt ,, p lrn! , The tary petrino muss he ohttaiiitd and postOd pilot to the start of arly Cf3; StrtlC"td 'l. r n .I IL !i 4 w P fY ri J) J) ' i? 9 � iyn � kL J rn !J f-U pa a f Pa cla i 2 ° x lyl , 2 A' r r r i