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HomeMy WebLinkAbout032-1005-30-300 7 0 § , c � \ ) � § 1 $ § $ � / 7 � $ R § \ S) � 0 / 0) c p - § � Es � ■ \ kf � k28 i 2 � � / \ £ m \ z £ 2 \§ . (D k 7 f » cc � c .� \ � 0 \ ) O ; k z c 2 Its im % k « ^ / C 3 2 � 2 8 � & a a .0 ƒ G 7 / / k ' L j � � � ) � CD 0 0 0 U) j v $ \ \ k = 3 2 C-4 \ \ 0 E 04 — \ 7 a cn § 4 ƒ J c 8 9 ' � 2 = o E § .6 -e § k \ \ § 4 � Z � I § s e ' y 2 . t = z a g a - & \ & k G a \ ) E i f g g CO 2 0 z / I & s m 4 . 2 Et \ 0 » lokli k kIL ! . � � ' 12/12/2006 09:38 AM Parcel #: 032-1005-30-300 PAGE 1 OF 1 Alt.Parcel#: 02.31.19.27D 032-TOWN OF SOMERSET Current X! ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-WINK, KENT J&TAMARAH S KENT J&TAMARAH S WINK 612 230TH AVE SOMERSET WI 54025 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *612 230TH AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE SEC 2 T31 N R1 9W SW SW LOT 3 C.S.M. Block/Condo Bldg: 6/1607 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 02-31 N-1 9W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 854/606 2006 SUMMARY Bill M Fair Market Value: Assessed with: 144934 318,300 Valuations: Last Changed: 07/22/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 58,000 183,400 241,400 NO Totals for 2006: General Property 5.000 58,000 183,400 241,400 Woodland 0.000 0 0 Totals for 2005: General Property 5.000 58,000 183,400 241,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 130 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 OWNER ,Ce �/���,C TOWNSHIP w ire SEC. ?_ _ T L4_N-R Zf W ADDRESS S3© .S�° ST. CROIX COUNTY, WISCONSIN SUBDIVISION ----- LOT 3 LOT SIZE S_ PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 9'7 3> � N INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used AMM Elevation of vertical reference point: Proposed slope at site: y SEPTIC TANK: Manufacturer: �.�- � Liquid Capacity: rue Number of rings used: le) Tank manhole cover elevation: Tank Inlet Elevation: �GYJ�O� Tank Outlet Elevation: �, 7 Number of feet from nearest Road: Front,(D Side, Rear, O 7�pd� feet From nearest- property line - Front 10 Side 10 Rear,O > feet Number of feet from: well F lop , building: 9� (Include this information of the above plot plan)( 2 reference dimensions to septic tank) ___ gRR RF.VRRSR gTnP PUMP CHAMBER Manufacturer: y Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: r/ Trench: Width: /Z Length:sf- Number of Lines: Area Built: �s Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ORear,0 Ft>Ioo Number of feet from well: >Za Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• Dated: -Z Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION IS ► 53707 State Plan I.D.Number: 5 , 'fi,, Sec. 28 ,T31-R19 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Somerset Ln ❑ 230th S olding Tank ❑ In-Ground Pressure Mound NAME OF PERMIT.HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE". Somerset WI 5402 Kent & T ' BEIgCH MARK(Permanent YeferYl point)DESCRIBE IF T FR L REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David Fogerty 289 S SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV, TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: J U ���� ❑YES ❑NO ES ❑NO BEDDING: VENT DI VENT MAIL.., HIGH WATER NUMBER OF OAD: PROPERTY WELL BUILDING: VENT TO FRESH / I ALARM: FEET FROM ! LINE: AIR INLET: ❑YES LNO < / ❑YES O NEAREST­40-1/-? /00 So /0 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: P PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP A CO T LS OP RATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) Y S O NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at h pth,of pl will LENGTH: DIAMETER: MATERIAL AND MARKING: g FORCE or excavation. (If soil can be rolled into a wire,construc Io all leas untie 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: TERIAL: PIT DEPT DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO. I R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW IPESi ABOVE COVER: EJ,EV.INLET, ELEV.ENJ N`� ' q PIP : FEET FROM LINE: � 7/bOr ! AIR INLET: t I IJ,i'il /AI' iC7 !yl t C# -1 ar�. 1 NEAREST� 7 too MOH 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 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 COMMENTS: PERMANE RKERS: OBSERVATION WELLS: NUMBER OF IPROPERTY WELL: BUILDING: FEET FROM LINE: �} v YES ❑J NO ❑YES NO NEAREST­40' Sketch System on Retain in county file for audit. Reverse Side. sI ATURE: SBD-6710(R.06/88) DILHR SANITARY PERMIT APPLICATION _ In accord with ILHR 83.05,Wis.Adm.Code !CM. �s —Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARY PERM #�2(I ❑8'f1 x 11 inches in size. ChIti. on 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 'o A %a Gc) %, S T , N, R E(or6v PROPERTY OWNER'S MAILING A DRESS LOT# BLOCK# �. — CITY,STATE ZIP CODE PHONE NUMBER 4lJBBIYI9IeN 14A OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑State Owned ❑ C LL GE* NEAREST RQAD v y slo' ❑ Public 1 or 2 Fam. Dwelling—#of bedrooms 3 PARGEI TAX NUMBER( ) 111. 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) PE A) 1. Lrl 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 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.) PROPOSE ft.) (Gals/day/sq.ft.) (Min./inch) ELF ATION r 3 3 6 Feet Feet VII. TANK CAPACITY Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION New istin structed Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic A pp Tanks Tanks Se tic Tank or Holdin Tank .— / Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plu er's Signature:(No mp 10H21MPRSW No.: Business Phone Number: a' 7 Y 6s-6 lumber's Address(Stree City,Sta ,Zip Co et 1 IX. UN /DEPA TMENT U E LY Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuin Agent Signature(No Stamps) Approved ❑ Owner Given Initial CC Surcharge Fee) Adv rse D termination -� . 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 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 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. Ill. 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.11/88) a 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/contractpr, ("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 ��C � Location of Property S W 14 5 (0 14, Section off- , T 3 ( N - R W Township -7 Mailing Address 1 so m eY S Zf-T— Zz c' � a Subdivision Name Lot Number Previous Owner of Property �.�-o �j 5� � L �•� yV�r Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? v Yes No / Is this property being developed for resale (spec house) ? Yes y No Volume 6 and Page Number U U as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed e V 2. Land Contract w/ ve/� d )"ap� #S• ®� �cac�r!e/� ,#, 3. • Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - PROPERTY OWNER CERTIFICATION 1 (We) eeAti6y that ate atatementa on thin 6onm ate true to the bed.t o6 my (out) knowledge; that 1 (we) am (an.e) the owneh(a) o6 the pkopehty deAcA bed in th.ie in6onmati.on 6onm, by vchtue o6 a wavcanty deed aeeonded in the 066ice o6 the County Reg.c,atet o6 Deeda ad Document No. ; and that I (we) �- pnea entLy own the p;Kopoa ed 4 to bon the a ewage pod a ptem (ot I (we) have obtained an a Aement, to nun with the above deeeh i,bed pKopetty, bon the ///W- , conetnucti.on o6 eaid byetem, and the aame hab been duty teco4ded in the 066ice o6 th County Reg.i,aten o6 Deeda, ad Document No. ) . SIGNATURE O1/OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 16 .- o6 8y JO - 70 - f2 DATE SIGNED DATE SIGNED DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA y WARRANTY DEED STATE BAR OF WISCONSIN FORM 2- 1982 i Harold J . scliachtner and margaret J. _ Schachtner, husband and wife conveys and warrants to kent J. Wink and Tamarah S. Wink, husband and wife as survivorship marital property RETURN TO Century 21 Somerset, Wi . the following described real estate in St . Croix County, State of Wisconsin: Part of the S W 4 of the S w 4 of Section Tax Parcel No: 2 ," T 31 N - R 19 W described as follows: Lot 3 of Certified survey map filed November 6, 1985 in Vol . "6" , page 1607 (No. 9) . As Document No. 406834. s This is not homestead property. (is) (is not) Exception to warranties: recorded easements and rights of way . Ov October 89 Dated this da of •19 �r.^ r_.. v� (SEAL) (SEAL) * Harold J. Schachtner * Margaret J. Schachtner (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGEMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. I Q 1t{ Personally came before me this day of authenticated this day of •1 g October ,19 8 9 the above named Harold J. Schachtner and Margaret J. Schachtner * TITLE: MEMBER STATE BAR OF WISCONSIN (11 1101, to me known to be the person s who executed the authorized by§706.06,Wis.Slats.) foregoing instr ment and acknowledge th sa e. / THIS INSTRUMENT WAS DRAFTED BY `2G john D. Walsh * John D. WISAil Ill"of,,,� Notary Public St. I .., �(f„`rt,ty,Wis. Si natures may be authenticated or acknowledged. Both M Commissi1T is er an04+�. ,(Ifs t,sta p>�ation ( 9 Y 9 Y DecPem�et 1� I���t �� are not necessary.) date: • + p „—) •Names of persons signing in any capacity should be typed or printed below their signatures. ' p ' WARRANTY DEED STATE BAR OF WISCONSIN % I VNA TORSI •SOCIATION FORM No.2-1982 14v'►flgvl•hfhd�q�,q'gCORSiR 53704 i SURVEYOR 'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereb y certify, that by the direction of Harold Schachtner, I surveyed, described and Y mapped the land parcel which is represented by this Certified Survey Map; that the exterior boundary oi the land parcel surveyed and mapped is described as follows : A parcel of land located in part cf the SW 1/4 of the SW 1/4 of Section 2, T31N, R19W, Town of So erset, St. Croix County, Wisconsin; further described as follows : in; Commencing at the SW Corner- of sa ' d ,Sect,:ion 2; said corner being the Point of beginning of this desc'ripaion; thence EAST along the south line of the SW 1/4, 1337 . 16 feet to the east line of the SW 1/4 of the SW 1/4; thence N00027 ' 26"E -°•al'ong said line, 652 . 55 feet; WEST, 1333 .18 feet to the west 1.in-P of the SW 1/4 ; thence .S00°48e2ce along said line, 652 . 59 feet to the point of beginning. 2 W, Above described parcel is subject lto an easement for Town Road ur on the south, and an easement for C.T.H. "I" on the west as shown pose s on this map; and all other easements of record. That this Certified Survey Map is a correct representation exterior boundary surveyed and described; that I have fullyocomplied with the current provisions of Chapter 236 . 34 ,1-s AAS:n Revi&,-d Statutes 'and the Land Subdivision Ordinance of the County of St. Croix in surveying and mapping same. w 4 •n y' ' S-1407 ' � 1 ' z Allen ' ZV; +rr? �,, C. Nyh a en i �'•'""40 K' o s U y I ( I I ' I H H F a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a H � OWNER/BUYER }�er,`1- -f- �yn�Y'��� (�) ;nJ ROUTE/BOX NUMBER ,, -- 11 Fire Number C ITY/STATE SnM p y .S e-t— (�t/� Z I S40 as PROPERTY LOCATION : 560 14, x, Section T31 N , RAW, Town of St . Croix County , Subdivision Lot number 3 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. H 0 E I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office wit in 30 days of the three year expiration date . SIGNED � DATE p JO o U 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 . INDUS DEPARTMENT Y, OF REPORT ON SOIL BORINGS► GS AND SAFETY �Ut�,Q►N( INDUSTRY, D f� �!`y+� t11N + �.w.. I li LABOR AND P.O.QQ*191 UP"AN RELATIONS PERCOLATION TESTS (115) MADISQN, 6�a. +, (H63.090)&Chapter 145.045) 0 ON: TOWNSHIP/MoNi@tp>r4UTY: OT NO.:BLK.NO.: SUBOIVISIO NAM , 4"�"a'- T L L N Y: OWN R-3f& t fert'! MA A )DRESS: �^ wt USE DATES OBSERVATIONS MADE N0.BEDRfvt4.: MM SC PTO : 71WI LE DES T$ v8esidence Olew ❑Replace I C .7-9- :5 ^Z 7� �... 13 A RATING:S-Site suitable for system U-Site unsuit§ble for system ' f.ONVENTI NAL: MOUND: IN-GROUND : S E • N-FILL OLDING TANK:RECOMME D D SYSTEM:loptionall t, ❑u R.S au ks EA os oS u if Percolation Tests are NOT required DESIGN RATE: r If any portion of the tested area is in the under 4.1-163.0915)(b),indicate: C.,Z7 43 ifloodplain,indicate Floodpiain elevation:.- PROFILE DESCRIPTIONS ► BORING TOTAL P H TO:R UNOWATER-INCHES HARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, 4%149-`XEPT NUMBER N. ELEVATION 0gSERVED H TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) s- Z 6 96 oa y!o �= ''mil I . �% .�;1• = .5.A,. 13-3 ' 5 75 r:. l PERCbLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUT�S NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PEA1013 3 PER INCH P_ P- P- P Y P PLOT PLAN: Show locations of percolation tests, soil borings and the d ansions of suitable soil areas. Indicate scale or distances. Describe what aril tfle N zrntal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the diregtion, �tgrq. o' land slope. r SYSTEM ELEVATION rpa _... _..__ _. ___ �_._ .__ _... _ _ ----- _ .,�.. I : I ' tL f i 'T 1 I I , s , 1, the undersigned, hereby certify that the soil tests reported on this form ere made by me in accord with the procedures and methods specified in the 1(1(tscon4 Ii Administrative Code,and that the data recorded ar.d thu location of the tests are correct to the best of my kriowledge and belief. ,. AME (print): ` TE§T N S WERGE COMP LET ED�ON: f,DDRESS CERTIFICATION NUMBER: PHONE NUM ER(nntional CST SIGN DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. PILHR-S8D-6395 JR.02/82) —OVER — 4 as C �s '1SN3 Joao 0,1 paensse Jo auTT 4 1nos ai;, ol pa0u3ja3a 1 s6ut�eag ,.. Y{ UJ e 4J r- ? A ►• 5 ' 'N'S'0 a rn �41 u cl fix' .i,. tj 'n� b t S aita �o VI NS aya jo autt Ise; tu I �I Z S7 h� Ly 1V' �I•C. all SS�ZS9 W W rr !} r /rN 3u9Z�LZo00N .t Z -'L" r ri o iii . +£ ,'',. � •-�lrJ � ,I �. 1✓ T MIM tp d•. i M M f1 1 N y{ I' M I M RH, is YSA• o co (c Z '�f,�� :y iSS'Z59 3n9Z�LZp00N yl c U. a co 41 L; M ri I . i=+ U MA C.► 1— V M ! 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