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HomeMy WebLinkAbout032-1003-90-000 � o � ° I y oo M U U v c a� a a 0 0 � rn et o r I - I LO o 3 p E H rn cCD � 3 c cj-y •h - I a� c fn I .0 0 � tl1 c I U m O� c L .. CD 0 Co C 0- O y a N y y>>� c 0^ O)O CL r? N d N 0 x c N N m N a CM c 'C Z y.�-. N y a 'C Z to N O 0 O C (a V C 7 v C y V CN k 0 LL g N y y €.w Q LL p y c p� _ U c p �+ -° ENE-0aao aci 3 v L0 (A :2 1 v Q uOroocf6i Q h°On° o ._- o M v m O > Z � � n 9 � 0 O 0 0 M w a m a m N H Z I I O Z c c p o N N (D Z v to H c aa) c' (D E E III N 0 7 N 0 7 M 0 N N CY CL N 0 N N C c (° O N L 0 L 0 0 0 N d d m m N h� O O ° N O 0 Q n O 0 Q �:• O Z m Z o Z m z o Z o N _ Z LO N h 0 n 0 C O .. A N C Lo R O U) a vooa` av 2ooCL � m E 3 3 3 CL Of 3 3 3 a m +� 0 0 0 2 0 0 0 •N � � a a a I � a a a IL a3i O ° eN J o o U 0) 0) LO rn rn o o Z CO co v Z ° 00 0_ o_ = a) 0) — o N Y 0 O O O w O O O M O O E N N N 'O N '° (O Cl) Lo CO m c U_ CO N c a O l0 O Z (n C y N N co d m � Q (n Q CN O O ° N C W H w 0 I L Vl C I O U E C y Qs O O MO M 0 M L) 0 V C p U pdo 0o l �+ M N Q N f6 Y N y .Y R 'O N N N N y C m N C 0 v Q M In 4.i O r N — m N ' M y D N O N O .y0. N 0 '00 M N N Z O 0 O •O � ° I _ I a o z y H o o n -j CD z N i z gin I I�1 Y V = E #k o � a ( a - • cd a d aD c y t A U a 2 0 m U 0 m U Form - S T C - 106 AS BUILT SANITARY SYSTEti KEPORT - OWNER _=� � _ TOWNSHIP /�. d�e�"Se1 SEC. _ TFN-RW CRESS �S ST. CttOIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distance• and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING HING WITHIN 100 FEET OF SYSTEM LAS 46 00 B� �Jr� G`l INDICATE NORTH ARROW SENCKHM: Describe the verticnl reference mint used 46"54- e-lr—4!5;4rp9t-'Al C Elevation of vertical reference point: /�� Proposed elope at site: SEPTIC TANK: Manufacturer: _ ��J`� L.t;vi d Capacity: i Number of rings used: c2? mnnhute cover elevation: S Tank Inlet Elevation:��j Tank OuL.I-L Ll.cvation: Number of feet from nearr r d: Front,w �c'^0 Rear, � "' /`/.5� feet From nearest propr.i. i.1ne Front, :•1.:1c,,ORear,O feet 4 PUMP CHAFER Manufacturer: Liquid Capacity: • pump Model: _ Pump/Siphon Manufacturer: Pump Site Elevation of inlet: Bottom of tank elevation: pump off switch elevation: Gallons per cycle: Alarm switch Type: Alarm Manufacturer: property line: Front, OSide, ORaar.O Ft.—..Ft.—..Number of feet from nearest p ro p Number of feet from well: , Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: T p� Width: ^/oZ _ LeniEh: Number of Lines: Area Built: 419Z Fill depth to top of pipe: .� Number of feet from nearest property line: Fr O aonG, Side.JQ 0 Rear O It Number of feet from well: g Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepase 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, ORear, OFt.___ Number of feet from well: li I Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: _ Dated! plumber on job: License Number: 3/84:=j 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: NE 4,NW 4, Sec. 2 ,T31-R19W ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of N. Somerset Holding Tank El in-Ground Pressure El mound E! H ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Kenneth Potting R New Richmond, WI 5401 QO Q / BE CH MARK(Permanent retgrence point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST RE .ELEV.: Name of Plumber: MP/MPRSW No.: County: a itary ermit Number: yron Bird Jr. 3318 St. Croix 153 52 3 'Y SEPTIC TANK/HOLDING TANK: MANUF CTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER �/ 'L pa PROVIDED: PROVIDED: Z'5/t '5 �0 D �l / 0 .0'YES ❑NO ❑YES ONO BEDDING: VENT DIA.: VENT MATL.: HIGH WAT R NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH (/ •••� ALARM: FEET FROM LINE: AIR INLET: ❑YES NO �i'� ❑YES NO NEAREST�� I I `5 / DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: P P MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP A Dr-opfrRIOLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) Y ❑NO NEAREST—� SOIL ABSORPTION SYSTEM. Check the soil moistur4&MAh de th of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,constjtFuction bAllceaseuntil MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDEDIA.: #PITS: LIQUID 1A ha A BED/TRENCH TRENCHES: /_ ERIAL: PIT I--"' DEPTH:/ DIMENSIONS /� 5 3 /— ll ' GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE DISTR.PIPE MATERIAL: NO.LI R. NUMBER OF PROPERTY WELL: BUILDING: VENT TESH BELOW IPES: A E OVr�: ELEV.INLET: ELEV.EI�1: PIP LINE: AIR I �^ FEET FROM /� Q ( 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 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: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST--- I-XIL' P - /� ( i tt lD ,C Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: 1 TITLE: SBD-6710(R.06/88) ` . '< }2' l ®ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code �Jf Gr o STATE SANITARY PERMIT# –Attach complete plans(to the county copy only)for the system,on paper not less than �_ 8%x 11 inches in size. ❑ Ch�vision o prev�ous application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROPERTY O N R PROPERTY LOCATION % '/a, S 62 T , N, R E(or PROPER OWNER'S MAILING ADDRESS LO T# BLOCK# CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD A ( ) El Owned VILLAGE: A*7er$! �r 9 ❑ Public 541 or 2 Fam. Dwelling–#of bedrooms EL TAX NUMBER(S) III. BUILDING USE: (If building type is public,check all that apply) 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 ZReplacement 3. ❑Replacement of 4. ❑ Reconnection of 5.El 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 El 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 13.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 CAPACITY VII. TANK Site INFORMATION in gallons Total #of Manufacturer' Con- Steel Prefab. Fiber- Exper. New istin Gallons Tanks s Name Concrete glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Siphon Chamber E 1 Vlll. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): , Plumber's ignatura:(No S ps), MP/MPRSW No.: Business Phone Number: Plum s d ass(Street,City,State,Zip Code), r IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing gent Signature(No Stamps) Approved ❑ Owner Given initial /��CC) Surcharge Fee) Adverse Determination a 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 thiasanitary 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. 111. 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 groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations-and establishment of standards. S8D-6398(R.11/88) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit Issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------------------- Owner of property Location of property /4 1/4, Section 7i , T N-R�,�,V Township '' Mailing address �n--� Address of site Subdivision name Lot number Previous owner of property 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)? Yea No Volume ' oo 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 Nap, the Certified Survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(Ve) 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 recorded 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 been duly recorded in the Office of the County Register of Deeds, as Document No. ) . Signature of Owner Signature of Co-Owner (If Applicable) �,- �29F 2 Date of Signature Date of Signature DOCUMENT No. STATE BAR OF WISCONSIN FORM 6-1982 THIS SPACE RESERVED FOR RECORDING DATA PERM=XIMPIESZKYWAMSX0800 397779 SPECIAL ADMINISTRATOR'S DEED -- CVO! PAGEI�.O� REGl6TERS OFFICE Myrtle LeMire ST. CROiX C,0. WIS. ---------------------------------------------------------------------------- ------------------------------------------------------Spec-i:al--Admirni-str-a+-©r------• Rec'd. for Record this 15th -------------------------------------------------., as UriA 1)QWX Lt %46 of the estate of day of NovemberA.D._ .,, 4 I,.eHi r_e_,...a/7sla--Edwasd--J-....Lamere-------------- d 8:30 A , .D ----------------------------------------------•--------------------------------------------------------•--------- ------------------------------------------------------------------------------------------ ("Decendent"), James 0'Unnel 1 for a valuable consideration conveys, without warranty, to ------------------­---------- R"MT� Kenneth J. Potting, Donald M. Potting and Deputy • ---- n.i.s---••---••P.o ---i ----------------------------------------- DennisE' Potting--------------------------------------------------------------------- •---------------------------------------------------------•---------------------------------------, Grantee, RETURN TO the following described real estate in ----------S :_._ 0 ------------------County, State of Wisconsin (hereinafter called the"Property") • one–seventh (1/7th) interest in: • four acre tract of land in the Northeast Tax Parcel No: ------------------------------ corner of the Northwest Quarter (NW4) of Section Two (2) , Township Thirty-one (31) North, of Range Nineteen (19) West, described as follows : Commencing at the North Quarter corner of said Section Two (2) ; thence South along the Quarter I ,�, ; Section Line, 580. 8 feet; thence West 300 feet; thence North 580.8 feet to the North line of said :��_" Section; thence East 300 feet to the Point of Beginning, St. Croix County, Wisconsin. This conveyance is given in satisfaction of decedent' s interest in land contract to Kenneth J. Potting, Donald M. Potting and Dennis E. Potting, dated June 30, 1974 and recorded July 3, 1974 in Volume 513, page 178, Document #322798. Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. 23rd October 1984 Datedthis ---------•---- • .............................. day of ----------------------------------- - --------------------------------•------ ------•----------------------------------------------- ---(SEAL) 27- f�� (SEAL) Myrtle LeMire ---------------------------------•--•------------•---•------- ............................ -•--•••---- - Personal Representative �nmginis ra Specia tor AUTHENTICATION ACKNOWLEDGMENT Signature(s) __Myrtle LeMire--------------------------- STATE OF WISCONSIN ------ -- ------ --- ss. -------------------------------------------------------------------•-------•--- --------------------------------------County. authen ' ted thi 3rd_day of----Q.C_tQ ..Q _____, 19._8.4 Personally came before me this ----------------day of 19........ the above named . Hendrik W. Van Dyk............ -----•-------------------------------•-•---••--•--•-•--•--- TITLE: MEMBER STATE BAR OF WISCONSIN (If not- ............................................................ -•-••••---•...__.....•------•----•----•------...................----- ......- authorized by § 706.06, Wis. State.) to me known to be the person ------------ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Reinstra, Van '......................°-......... ............................... Dyk Needham, S.C. s -New-_Richmond_,_ W41 ..............................................................................-------------- Notary Public ..........................................County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration are not necessary.) date: *Names of persons signing in any capacity should be typed or printed below their signatures. L STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 9 � OWNER/BUYER ' ROUTE/BOX NUMBER � .`� lS� FIRE NO. CITY/STATE ZIP 5��6/ 7 PROPERTY LOCATION: 1/41/4, Section 2- , T�N, R W, Town of 1, St. Croix County, L.._ 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 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 ._..,.. . _.._ _.._.._....,.tea DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION .LABOR AND PERCOLATION TESTS (115) MADISON WOI 53707 ' HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: OWNSH /MUNICIPALITY: O VISION NAME: COUNTY: �j MAILING ADDRESS: f ? ,/�/.7 d Y. Cad/r ��i/ !' ��' 7 d � Q4� !��/�J��/Q C.G// 7' K USE DATES OBSERVATIONS MADE y NO.BEDRMS.:ICOMMERCIAL DESCRIPTION R A TESTS: %Residence � ❑New ,Replace RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: M IN-GROUND-PRESSURE: SYSTE -IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) EA S ❑U ®.S ❑U S ❑U ❑S ❑S ®U 115- If Percolation Tests are NOT required DESIGN RATE: [Floodplain,f any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- /1/0 1-7 7 e2 7.2— 1017 sue, B- B- f PERCOLATION TESTS t TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES t NUMBER f0Yit1GC AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RIOD2 P R PER INCH P- aZ o-mac G P- j G 3 P- 6 G 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 A rf' OS . ), , a E E ---------. __ P � E E LDe7 r � E 1r.+y 3 P 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)- ITESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIGNA RE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-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. State of Wisconsin Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL SAFETY&BUILDINGS DIVISION Office of Division Codes and Application 201 East Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 BYRON BIRD JR. Owner: KENNETH POTTING ROUTE 4, BOX 6 ROUTE 2, BOX 150 AMERY, WI 54001 NEW RICHMOND, WI 54011 RE: Plan Number: S89-40399 Date Approved: October 12, 1989 Gallons Per Day: 450 Date Received: October 12, 1989 Project Name: POTTING, KENNETH - RESIDENCE Location: NE,NW,2,31,19W Town of NORTH SOMERSET County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved' . This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT CONVENTIONAL NOTE: This approval does not include plans for the general plumbing systems or sewer piping to the septic/holding tank that is required for this project. Those plans must be submitted and approved. a Inquiries concerning this approval may be made by calling (608) 266-6952. Sincerely, i L�� GERARD M. SWIM Section of Private Sewage Division of Safety and Buildings cc: KENNETH POTTING X Private Sewage Consultant SBD-6423 (R.08/88) i rLV I PLAN t ;PRO4CT e,/,,J( O ZA ADDRESS de /s 9 X ' 11141/4/S /T�� N/F�J�` TO WN /. �r ti COUNTY�FS MPRS Byron Bird Jr. 3318 DATE BEDROOM -;g PERC_�CONY NTIONAL IN-GROUN ESSURE CONVENTINAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA J" 506 PERC RATE `ABED SIZE ► Benchmark V.R.P. Assume Elevation 100' A Location of Benchmark * H.R.P. CJ Borehole Q Well Scale = Feet 0 Perc Hole System Elevation Uent 'Z» This approval Coca; rot incis%ic plans for the genera plumbing systems ar sewer PTIN to the septic/holding tank that is iuiu^;c;; 1- project. Thr+se plans must be submrtu:d aed a,;provcd in accordance With 18 MIN. Ch ILHR ^2 `AA, TYPAR COVERING 2» — 12» 3' 4 6' O 3' ' /fe�dir 1 6" Sewer Rock 12' 3 Vol �• — Q r - o"' ,z �5 50 Y4A=f I�vtl 0EPA UIVENT QE I Q t � F'�7.,��r'iN ELATIC"JS �/ r� . AffaOX, tACAFRON of eAR SEPTt G 1 � N ■/p H IG �p Za 1� C t � kA �, �. �00 U r 1 ,Plb 60 �3 2 3-16 alO AM 71-'a77_1 V C� S NAME OF BUSINESS LOCATION rest or ay 3 g/ (oS� city r township county <Z S-fi-�e.e�f LEGAL DESCRIPTION OWNER Mailing address lM� ZIP ARCHITECT OR ENGINEER Address ZIP PLUMBER Address s 2IP i 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed:�/ Existing building New building Addition /l i If addition to existing building attach detailed memo for each. ( ) Drive in restaurant . . Car spaces ( ) Restaurant . • . . . . . Seating oapaAi� 10 sq. ft./person) O Dining hall . . • • Per meal served Toilet waste Yes No O Motel O Hotel ( ) Cottages • . Number of unitst 2 persona/unit 4 persons unit TOTAL NUMBER OF UNITS ( ) Churches . . . . . . • Number of persons Kitchen Yes No (Y� Bar or cocktail lounge . . . . Seating capacity (10 sq. ft./person) ] ( )Nursing or rest home . . Number of beds Mobile home park . • . . . I ( ) pa Number of units - dependent (camper trailer) - nondependent (mobile home) ( ) Retail store . . . . . • Number of employees Number of customers (10 sq. ft./person) O Service station . . 9 Number of oars served­7 y) ( ) School . . . . . . Number of classrooms Meals served Yes No Showers provided Yes No O Factory or office building . Number of persons (total all shifts- ( ) Residence . . . Number of bedrooms ( ) Apartments . . . . . . . . . . Number of bedrooms ( ) Other . . . . . . . . . . . . . Specify 2. Indicate whether or not the following facilities are oonneotedt Food waste grinder . Yes No Dishwasher . . . . . Yes No Automatic clothes washer Yes No 3. Fill in the appropriate information for the following as indicateds Septic tank capacity planned TOTAL Septic tank capacity required /C 0 Li o_[� Percolation test results • ATTACH PERCOLATION TEST 4MPORT SHEET Seepage trench bottom area planned width linear feet depth Seepage bed area planned T 1/width /y. linear feet '? depth Seepage pit planned "" ousde diameter"` depth below inlet -'depth " Seepage trench bottom area required, width linear feet, depth Seepage bed area required « width 4_2 linear feet S.<' depth 1.//4 Seepage pit required �. `�. ,. outside diameter depth below inlet Signature of person completing form: STATE DIVISION OF HEALTH, PLILMB G SECTION P. 0. Box 0 , dison, �discons 53701 Address Approveds 470mo • 7—ZIP Dates Dat es Z 0 j 971 THIS APPROVAL SHALL BE VOID IF THIS APPROVAL S> 411 8E pOO IF if q.R�D �—•�'�' NOT INSTALLED WITHIN TWO YEARS WITMOUT THE VRITTEN APPROYAL !N{THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIRtF.MENTS AND DOES NOT EXEMPT THE FROM THE DATE OF APPROVAL DIVISION OF�HEAI "_ INSTALLATION FROM CITY, VILLAGE, TOWN- SHIP OR COUNTY REGULATIONS OR PERMIT (OVER) REQUIREMENTS.