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HomeMy WebLinkAbout030-1057-70-300 ~ C) h .~ O 6 0 0. o krl Q5 1 2- m v °oo N �•-- L c7 N N O L . 0.0 X Z`1 1 CL N y a) N ca r- a, i c a) 3 to U C Z 0 � a) C t l m o CD a) LL O t O u) y Cl Y 3 LE3 EEC Q � �� I I 3 M Z y rn w E Z = 0 ° w a m N M N F- Z 0 O Z c Z v � c o N a) c N a) a Q) O 1 O N O O 0 Q w Z m Z o r 0 d Q �O`+ c N N d a) c ° o G D a U .O zv > .. O O O z •�V a a a 0 g E ) o N E 0 !� J U � rn rn Z l = E O V, o p M m m c a I •p d Q } (n ca E LO O M �- p O O d 0 0 c U -0 p n O c _ it 04 CL CL I C W W a) O U, a) o a, a) c C • iii O o C; o '0 ) ° M o N o (n U) O Z I- U) I E `m I a #c CL a • Q d ,V 0 `1V E c c 0 7 3 0 �1 A L) IL 0 v) c) Parcel #: 030-1057-70-300 02/24/2005 05:08 PM PAGE 1 OF 1 Alt. Parcel#: 23.30.19.2011 030-TOWN OF SAINT JOSEPH Current Xj ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner * RANDY E&RACHELLE R HASLOW HASLOW, RANDY E&RACHELLE R 696 N BAY RD SOMERSET WI 54025 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *696 N BAY RD SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 7.030 Plat: N/A-NOT AVAILABLE SEC 23 T30N R1 9W LOT 4 CSM VOL 6/1738 Block/Condo Bldg: ASSESSED WITH P179B Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-30N-19W Notes: Parcel History: Date Doc# Vol/Page Type 02/14/2003 709669 2141/573 WD 07/23/1997 1175/420 WD 07/23/1997 836/456 07/23/1997 827/43 more 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 5217 242,300 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.030 86,500 151,900 238,400 NO Totals for 2004: General Property 7.030 86,500 151,900 238,400 Woodland 0.000 0 0 Totals for 2003: General Property 7.030 50,700 124,500 175,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 107 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 • Form — S T C — 104 AS BUILT SANITARY SYSTEM REPORT e� SEC. Zv T N-R W OWNER 'TOWNSHIP �7T%�/�"'r ADDRESS LEA y /t`r) ST. CROIX COUNTY, WISCONSIN SUBDIVISION /( LOT LOT SIZE CS M "!PLANS VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM" rj/) J1V� � w' r Le- f r 3 �I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used �j�/�/f IN Elevation of vertical reference point: L( ,K` Proposed slope at site: SEPTIC TANK: Manufacturer: ' — � Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: . r -_ Tank Outlet Elevation: 101, 61 Number of feet from nearest Road: Front,Side Rear, 0 �iC Y: feet From nearest property line Front 10Side,wRear,O ' ,S feet Number of feet from: well _ j" , building: :.7 G' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE d PUMP CHAMBER ' I Manuf cturer: Liquid Capacity: a Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tan evation: Pump off switch elevation: �` lons per cycle: Alarm Manufacturer: Alarm tch Type: Number of feet from nearest property line: Front, Rear,© Ft. Nu r of feet from. well: mber of feet from building: ( ude .distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Lenith: `7 > Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ( Rear,OFt . Number of feet from well: ` d Number of feet from building: / )2 (Include distances on plot plan). S PAGE PIT ,. ze: Number of pits: Diameter: Liqu depth: Bottom of seepage pit elevation: Area Buil Has either a drop b6X0 or distribution box beZused ny of the above soil absorbtion sytems? (Check, one). HOLDING TANK Manufacturer: pacity. Number of rings used: vaton of bottom of tank: Elevation of inlet: Number of feet from ne at property line: Front, O Side, j%ear, 0Ft. ber of feet from well: umber of feet from building: umber of feet from nearest road: A Manufacturer: Inspector: Dated: _ '— Plumber on job: License Number: C <h 3/84:mj Parcel #: 030-1057-70-300 02/24/2005 05:02 PM PAGE 1 OF 1 Alt. Parcel#: 23.30.19.2011 030-TOWN OF SAINT JOSEPH Current IX ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner * RANDY E&RACHELLE R HASLOW HASLOW, RANDY E&RACHELLE R 696 N BAY RD SOMERSET WI 54025 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *696 N BAY RD SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 7.030 Plat: N/A-NOT AVAILABLE SEC 23 T30N R1 9W LOT 4 CSM VOL 6/1738 Block/Condo Bldg: ASSESSED WITH P179B Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-30N-19W Notes: Parcel History: Date Doc# Vol/Page Type 02/14/2003 709669 2141/573 WD 07/23/1997 1175/420 WD 07/23/1997 836/456 07/23/1997 827/43 more 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 5217 242,300 Valuations: ast Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.030 86,500 151,900 238,400 NO Totals for 2004: General Property 7.030 86,500 151,900 238,400 Woodland 0.000 0 0 Totals for 2003: General Property 7.030 50,700 124,500 175,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 107 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i DERAR'i MENT OF INDUSTRY, INSPECTION REPORT FOR ' y SAFETY&BUILDING LABOR&HUMAN RELATIO DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: ND,- NV,-,S22,T3 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of St. Joseph ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound P OL ER: ADDRESS OF PERMIT HOLDER: INSPE TI D E: Robert Swanson Route 1, Box 507B, Houlton, WI 54082 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: Donavin Schnitt 3205 St. (koix 119439 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---1110- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: I MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE 7bISTR.PIPE DISTR.PIPE MATERIAL: NO DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET:I ELEV.END: PIPES: FEET FROM I LINE: AIR INLET: NEAREST---10- MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: []YES ❑NO [:]YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: 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: 1AREST- MBER OF PROPERTY WELL: BUILDING: COMMENTS: ET FROM LINE: r El YES ❑NO ❑YES ❑NO ♦ I F 5� 7 Retain in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE: Zonin Administrator SBD-6710(R.06/88) --� SANITARY PERMIT APPLICATION cou TY LJ 01LHR In accord with ILHR 83.05,Wis.Adm.Code �`�" ape/ u _. v' t_ STATE SANITARY PERMIT# -Attach complete plans(to the county copy only)for the system,on paper not less than 119V39 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. PROPERTY OWNER PROPERTY LOCATION _ ` '/a '/4, S T ®, N, R E(or) PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C N®BER d 2 1 Gy NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑State Owned vl AGE;S�- i gr ❑ Public LginL 1 or 2 Fam.Dwelling-#of bedrooms 7ARCEl TAX NUM ER( 30— /05 7_. 7,&-,3 Ill. BUILDING USE: (If building type is public,check all that apply) Q s 01 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 [1 Medical Facility/Nursing Home 10 El 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. N 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 ICI 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. ELEVATION GRADE REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 1 A I 8 Feet Feet VII. TANK CAPACITY Site allons Total #of Fiber- Exper. in Prefab. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App structed Tanks Tanks Septic Tank or Holdin Tank 'S 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): Plumb Signature:(No Stamps) /MPRSW N Business Phone Number: OJAI Plumber's Address(street,City,State,Zip Code): U LL IX. COUNTY/DEPARTMENT USE ONLY Disapproved Saanitary Permit Fee(includes Groundwater Date Issued ssuing Agent Signature(No Sta ps) ❑ Surcharge Fee) Approved ❑ Owner Given Initial ``/� � Adverse Determination / -7 ` CJ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber INSTRUCTIONS r ' f , 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 t 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: L 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'f 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-2roundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6M(R.11/88) DOCUMENT N0. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED ' 446436 VOL $36 456 REGISTER'S OFFICE ST. CROIX CO.,WI RICHARD 0 STOUT , JANET P. STOUT and R@C'd for Record MAUD H. STOUT MAR 3 01%9 conveys and warrants to ROBERT W . SWANSON aegtsNrefO'�" RETURN TO the following described real estate in St • Croix County, i State of Wisconsin: Tax Parcel No: Part of the NE 1/4 of the NE 1/4 of Section 22 and Government Lot 5 of Section 2.3 , all in T30 N, R19W, Town of St. Joseph, St . Croix County, Wisconsin, described as follows : Lot 4 of Certified Survey Map filed November 7 , 1986 , in Volume 11611 , page 1738, #419094 , TOGETHER WITH a road easement for ingress and egress as recorded in C .S .M . Vol . 3 , page 861 . This deed is given in partial satisfaction of that certain land contract dated November 7 , 1986 , and filed in the office of the St . Croix County Register of Deeds in Book 772 on page 289 as Doc . No . 423547 on March 23 , 1987 , and as- signed on July 1, 1988 to Robert W. Swanson. TRANS a This 1R nrLt homestead property. FEE (is) (is not) Exception to Warranties: Dated this 28th day of March _ 19-8-CL-• (SEAL) _Mal k-o� . � 14Q 4�+114AP0 O Richard 0. Stout Maud H. Stout, by Richard 0. tou t ' 1 .11k 11 burney (SEAL) (SEAL) Janet P. Stout AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. authenticated this day of 119 Personally came before me this 28th day of March 19 c9q_the above named Richard 0 Stout and Janet P. Stout TITLE: MEMBER STATE BAR OF WISCONSIN ., (If not ,L X11% to me known to be the person 8 who executed the authorized by§706.06,Wis.Stats.) Y, Fip�,Iorego1ng instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Janet P Stout 1 An }- a= A P U © 1"\ , gllary Public County,Wis. (Signatures may be authenticated or acknow'g @d. Both v My.Commission is permanent. (If not, state expiration are not necessary.) Q F'VJ tJ. date:-S 19 ) Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 7774 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms,P.O.Box 10208,Green Bay,WI 54307-0208 Form No.2—1982 ' z cn H a ST C - 105 r r a SEPTIC TANK MAINTENANCE AGREEMENT H o . St . Croix County z d a OWNER/BUYER RQ/3El? T tS20A/11AA/ ROUTE/BOX NUMBER ./?T / 00x �!E(,-7 j3 Fire Number CITY/STATE 11E.fG1��r _( ..� ZIP 5yox2 PROPERTY LOCATION : Me k, me !4, Section-"1, T 30 N, R _W, Town of ,S'/T� ����C� /{ , St . Croix County , Subdivision_ ,5'700 Lot number_. I Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St . Croix. County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , 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. .� 0 E I/WE, the undersigned , have read the above requirements and agree z En to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment 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 o- DATE St . Croix County Zoning Office P . O. Box 98- Hammond , WI 54015 715-796-2239 or 715-425-8363 Sign , date and return to above address . 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 RQ 13FRI: S60-'I&te/ Location of Property - k , ._fit, Section , T_j�N-R 9 W Township `571 / Mailing Address /�f, � �ox ,6Q�,& dial LTOot< /Y/T' - Address of Site � , 6 � J Subdivision Name� / Jf r0a T . Lot Number '7 Previous Omer of Property &#APQ s 140a T Total Size of Parcel 7 Acne S Date Parcel was Created 0�4L Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? 4K._ Yes No Volume _f � and Page Number 6 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 IWO cvtti.6y that aCt h.tatementh on .thin 6okm ane tAue to the but o6 my (ouA) hnowtedge; that i (we) am (cute) .the owneAk l o6 the phopeJety de�scAi.bed in .th,i,a .in6onmatEon 6ohm, by viAtue o6 a WaAAanty deed kecoAded in the 066ice 06 the Cc m tyy RegiA Zed. o 6 Deeds az Document-No. and that 1 (We) pried entty aun I pnopoaed Aite bon the Aewage dthp S . eyss em (on 1 (we) have obtained an ears er+ent, to nun with the above de!s cAibed pnopeh ty, bon the eonAtAuc ti.on 06 said system, and the dame ha.e been du.t n.eeonded .tn the 066.tce 06 the County Reg.ie.teA o6 Oeede, ab Vowmen t No. ) . SIGNATURE OP OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED ' i I I � , i I l } . I I c � I I o ,�q, I� j1 h1 / - -- - Mc 1 : I I � , I I ' ' I r I I I I II r I I I I I I I ', � Iy' ice _- a _ i � I I 1 I . C - +- I I t J RF j1. t r . i DflAa, - a - I , _ I t I T , _ -- - - , L ✓ — - - — _ I l ' U; i0 ! I I I I I I I -I I I - 1I I j , I I I I I f i f I I J , I i a I � f r , { II f II _ it t I , i I I j II ! I I - � I I I _ I ; . 1 -- I i - -f � I I-- t _ t I f r I , J I - - - - - t � I I , 7 I _ I I I} I -- -J i I I f I I I I I I r I [ I j _ I f j i - - - it .11i,�� rNDUSTR DiIEPARTMENT OF REPORT ON SOIL BORINGS -iV���� ��� ETY& BUILDINGS �' .�` DIVISION HUMAN AND PERCOLATION TESTS 1 q9� .'p,� Q. P.O. BOX 7969 HUMAN RELATI NS 1p (' ,� DISON,WI 53707 • (H63.090)&Chapter 145.045) d' IiA" I9 /' C LOCATION:/ SECT ON:T TOW`SHIP/� ,; OT, BLK SUME AME:FI�/ .Z Z/1'n N/R i�(or)W 5 r Cl '� COUNTY: OWNER'S/ A D Grol �� OAT �r USE DATES OBSE NATIONS MADE NO.BEDRMS : COM AL DESCRIPTION: PROF ONS: A STS: Residence ' New ❑Replace r RATING:S-Site suitable for system U-Site unsuitable for system NVENTI�AL: MpUNp;❑� IN-G�� ❑�R : S�E .FI LL HOQLDING TANK:F3C OOMMENDED SYS�M:(QO`p{�onaq If Percolation Tests are NOT require/ DESIGNp9ATE: If any portion of the tested area is in the Al under s.1­163.09(5)(b),indicate: -c-i Floodplain,indicate Ftoodplain elevation: PROFILE DESCRIPTIONS O BORING TOTAL DEP TH T R UNDWATER- CHARACTER OF SOIL WI THICKNESS.COLOR,TEXTURE,AND DEPTH NUMBER DEPTH W, ELEVATION OBSERVED H TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B' ( ?2. 2 o jU C- 4fs/ -/ / 3. 7- 1 _)G,l )VO616 4015d; 6 - • y2- 7 B- 7 Z - �7/�// l G - naQ a ,z - I yy- 1• B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFT R SWELLING INTERVAL-MIN. PR 0131 P901 PER10133 PER INCH P y U E !d 2 2. ,? P- S- IV - v 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 percW. of land slope. SYSTEM ELEVATION 61 y L 9 f I , - Ica 1,5163.,_Qo K>r n; ! ► , ,�.� 1. L � , I , r }_. gyp o : e r d. Te,.S'T 1 = /0(i4Q i 4% l V _ � I I I 1 ! Ilse, ! 1 I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the ocedures methods spedlf i the con n Administrative Code,and that the data recorded and the location of the tests are correct to the o my knowledge a lief. 1 �' NAME(print% , TESTS WERE COMPLETED O Q% � O L.-1 Q� f 2 -- Z. L/ A R S: CERTIFICATION NUMBER: IPHONE NUMBER(optional) CST NATURE t i 7RIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. LHR-SBD-6395 (R.02/82) -OVER - l