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HomeMy WebLinkAbout038-1116-60-000 N p °"� c ao �r o t� cc co 0 I N U U N O N O N O L 7 CU Cp I y Y L (q 1 O E N "O �O N N Y f9 N O �rn �LO Co w NQS U to c Z 0 rn N L m E v n C o � ° ca �U� M z E C2 z c v O L z a w CN F- z O O 2 0 U CD Z d 2 C O fq F- III C N zz -O N M O CU J� N m CD N �N •1 (n Al L — I ni O o N Q w Q z m z o Z N N LO % N ^r L V a 0 - O a) 0 o O G a a m w co tv� E >` n ►�a a m 0 0 0 z • is M a a IL I' ( Vl J U CO E oo co O (D 0) Z � I I oo :3 E T .8 CY1 N GSS (U } 10 O O O C CA N C y' 00 0 C6 O O W CO ~ O C C O C U £+ O > a- a v O °2 a m °O u, Z Z cn 00 E E c • T� M (A O O y O O " U V °' #a n da G CL a .� a) d r`1�1 E i c c Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER GL/r//IA ) TOWNSHIP _ �+ �Yc SEC. T,��N-R_ ADDRESSyjr/55 ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE— PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i 1� t 9� �ve� 1 fit" �dr INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used v Elevation of vertical reference point: /�� / Proposed slope at site: SEPTIC TANK: Manufacturer: _//�i�e Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation:_ ;2 `� Tank Outlet Elevation: �e i Number of feet from nearest Road: Front,O Side,O Rear, p feet From neare8t, property line : Front,0 Side,�Rear,' �Sp feet Cr�L�� Number of feet from: well J , building: 3s' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER Manufacturer: 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,O Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width:_ Z.;7 / Leng`Eh: Number of Linea: Area Built: ! ' Fill depth to top of pipe: ,?,o Number of feet from nearest property line: Front, O Side, O Rear,O Pt . Number of feet from well: r//g �t Number of feet from building:' Gfy- (Include distance on plgan). SEEPAGE PIT Size: umber 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: 02 D Plumber on job: i4 License Number: Z �( 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING 'LABDFC&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: N�Jj,N(�1i;S29,T3IN-RI 8W CONVENTIONAL ❑ ALTERATIVE (If assigned) TUWVI a6 S atc Ptcaur%e ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound 4 —2p._ Co MtWOAERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 'aVI, Route 1, Box 155A, Someuet, W1 54025 1 BENCH MARK(Permanent reference p DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: BytLon Bdhd Jtc. 3318 St. Croix 119400 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑YES ❑NO ❑YES ENO– 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: PROVDED: ❑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—� SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH MATERIAL AND MARKING: shall cease until or excavation. (If soil can be rolled into a wire,construction the soil is dry AIN h to continue.)Y enou 9 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 El 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 PERMANENT MARKERS: OBSERVATION WELLS: 4AREST.MBER OF PROPERTY WELL: BUILDING: COMMENTS: ET FROM LINE: ❑YES ❑NO ❑YES ❑NO � 7, ( � `72� 0 0 7. 3o 0 � Sketch System on Retain in county file for audit. Reverse Side. sIGNATURE: nTLE: Zoning Alinin 6tAatotc SBD-6710(R.06/88) SANITARY PERMIT APPLICATION COUNTY T DILHR - Gy f x In accord with ILHR 83.05,WIS.Adm.Code STATE SANITARY PERMIT# ./l q-�rov —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 12-1 NO PROPERTY WNER PROPERTY LOCATION tcc CJ'/< '/a, S T , N, R E(or PROPERTY OWNER'S MAILING ADDRESS it LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CIT STATE ZIP CODE PHONE NUMBER CITY NEA , ROA AKE OR LANDMARK VILLAGE: I"Airp' II. TYPE OF BUILDING OR USE SERVED: p )'� ' N� . b3 —l� 0_0C/0 Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. 54 New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. Z Seepage Bed b. ❑Seepage Trench c. ❑Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 0d 1 � Feet Private El Joint ❑ Public CAPACITY Site in allons Total #of Prefab. Fiber- Exper. VI. TANK INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass Plastic App Tanks I Tanks Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): ` Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:�2 A10%)Agip"C Plumber' Address(Street,City,State,Zip de): r Name of Designer: d �' ►^ �'t� ✓` Vlll. SOIL TEST INFORMATIO Certified So Tester(CST)Name CST# 3 CST's SS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(N Stamps) ¢r c Approved ❑ S harge Fee Owner Given Initial `[f� � Adverse Determination c� U X. COMMENTS/REASONS FOR DISAPPROVAL: ' SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; Vl. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/s 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundter included the creation of surcharges (fees) for a number of regulated practices which Wisco 11'1'1 can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Ire Sttf'R e is used in your building is returned to the groundwater through your soil absorption ` a system or the disposal site used by your holding tank pumper. I The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, t it's worth protecting. SBD-6398(R.03/86) APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owners) 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 '-" z �� Location of property.)Tj`1/' 1/4 1/9, Section , Tff,�_N-R W Township /(J Mailing addressn�lL.�p ,G�> Address of site Subdivision name Lot number Previous owner of property ��� � ,,c �nJi/ Total size of parcel ���C.�� Date parcel was created Omsk Are all corners and lot lines identifiable? —Yes No Is this property being developed for resale (spec house)? Yes _N0 Volume -�5-65S and Page Number � as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. —.7,/ q 4�j D ; 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 ounty Register of Deeds, as Document No. ) . Signature of Owner Signature of Co-Owner (If Applicable) to of Signature Date of Signature DOCtNENT'N0. STATE BAR OF WISCONSIN-FORM 2' 3 19'6 RESERVED N F DREG THIS SPACE RESERVED fOR RECORDING DATA BY nUS DEED, Earl We Cloutier & KAthleen B. REGISTERS OFFICE Cloutier, his wife ST. CROIX Co., WIS. Recd for Record this_Sth__ Grantor conveys and warrants to LaVina W. Sontag day of p!cemb!r_-A.D.19_73` at--A.-00 _ P:_ M. f kaFtlstar of Dands Grantee_ for a valuable consideration RETURN TO i the following described real estate in St• CrO iX Count s of Wisconsin: i A parcel of land in the Northwest } Of the -Nort west Tax Key r of Section 29, Township 31 North, Range' 18 West, of i' the 4th Principal Meridian, located in and forming a This in homestead property. t part of the Town of Star Prairie, more particularly described as follows: Commencing at the Northwest corner of said Section 29; thence East, 912.40 feet; thence; South 7.510 feet; thence South 07012100•" Walm,t 337.90 feet; thence South 68032#00" East, 264.00 feet to a point in a meander line of the Apple River; thence South 1803610011 West 201.4.5 feet along said meander line to the point of beginning; thence South 26048100" West, 322.72 feet along said meander line; thence South 64°42100" West 3.6,80 feet along said meander litre; thence North 71024940" West , 633.33 feet to a point in the 1 East right of way line of County Trunk Highway "C thence Northeasterly along said right of way line, on a curved line, concave Southeasterly, havin a radius of 1,382.39 feet and long chord bearing North 34041139" East an arc distance of 431.52 feet; . thence South 64048109" East, 590.65 feet to the point of beginning, containing 2.42,884 squre feet or 5.576 acres, together with land between the meander line and the Apple River. r - I - TRANSFER PException to warranties: S10. 00'EE Executed at Hudson Wisconsin this_.. 4t day of Dece �._.__ . i9 73. I, h SIGNED AND SEALED IN PRESENCE OF lif/r (SEAL) 13arl W Cloutier I� (SEAL) Kathleen B. Cloutier I) (SEAL) I� (SEAL) (I I; II Signatures of - - - authenticated this _ day of 19_- i Title: Member State Bar of Wisconsin or 3119M)Mb" Authorized under Sec. 706.06 X36. I' STATE OF WISCONSIN Ramse as. ' - ---- -� Personally came before me, this 4th _ day of December 1973, l the above named Earl_W__ Cloutier and Kathle8t] � Clog tier- to me known to be the person___: who executed the foregoing instrument and acknowledged the some. Pke�i / I I (e c-ee ifThis instrument was drafted by ffHugh F. Gwin Ramsey county., rws. - - - - --- ----- = �— Notary Public , i b:1 ay 7.1980 5 Ii yiVY11vWWVwvvw✓v�h >< / y The use of witnesses is optional. My Commission (Expires) (is) 'I , (' Names of persons signing in any capacity should be typed or printed below their sIttzu. '`/ © ii WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. T - 1971 BOOK C 633 KCAMINrCa.�ryiry� L�_ STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBE R FIRE NO.1--�_IX-7 CITY/STATE !:�2 , DJ ZIP .5L d--'7S- PROPERTY LOCATION: 1/9 1/9, Section 2 T 2 LN, R_/.� _W, Town of tit p , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation Prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. - SIGNED DATE ` L✓ St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street _ Hudson, WI 59016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, ___ DIVISION •LABOR AND PERCOLATION TESTS (115) P.O.MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1)& Chapter 145) T N:T TOWNSHIP NICIPALITYS LOT NO.:BLK.NO.: SUBDIVISION NAME: COUNTY' OWNER ELU R'S NAME: .� MAILING ADDRESS: o a v l 5On/cam xf �/7 d A,t r ,c Eve A USE DATES OBSERVATIONS MADE $( NO. E MS : COMMERCIAL DES R PTION: F TESTS: Residence ^�� JNew ❑Replace / —� •� RATING:S=Site suitable for system U=Site unsuitable for system ONVENTIONAL: MOUND: IN_ -GROUN :ESSUR S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) �S ❑U S ❑U 9S ❑U I DS COU EIS 0 1 63a If Percolation Tests are NOT required DESIGN RATE: 4 If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate' Floodplain,indicate Floodplain elevation: / PROFILE DESCRIPTIONS BORING TOTAL DWTH TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH ELEVATION NUMBER DEPTH IN, OBSERVED EST.HIGR_ES TO BEDROCK IF O SERVED (SEE ABBRV.ON BACK.) B-1 B- B- 3 B- lev A B- ��t PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP WATER L V L-IN HES RATE MINUTES NUMBER 11111111111111111116 AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PER INCH P-1 P- ;1 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 L546? , led 6e t 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): w TESTS WERE COMPLETED ADDRESS: r CERTIFICATION NUMBER: PHONE NUMBER(optional): CST S GNATURE: r DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) —OVER— NLUr PLAN PROJECT-/--A C-1�,2 u Y Levi iI ADDRESS ; � ,� /1/4 few 1/4/S�2 � N/R /� TOWN' r _ COUNTY Gvi` 55` S M RS Byron Bird J . 318 DATE BEDROOM CLASS PERC CONVENTIONAL_ IN-GROUN 'PRfSSURE CONVENTIONAL LIFT MOUND_HOLDI TANK SEPTIC TANK SIZE ,-z— LIFT TANK SIZE DOSE TANK SIZE /J HOLDING TANK SIZE ABSORPTION AREA Q PERC RATE /° BED SIZE Benchmark V.R.P. Assume Elevation 100' Location of Benchmark 6 .4 ��'' { 7 , c C, * H.R.P._ ;? e5v 0 Borehole Q Well Scale = Feet O Perc Hole System Elevation Uent Grndp- 12" TYPAR COVERING 2" 12" 3' O 6' 4O 3, 6 Sewer Rock 12' I V 7 X �� \� .. .qtr.,'• .014' u rt ° G N U, C rt O N O O rt' O cJ) '0 _ ro O O m I I•j r� ', '^ 5 r, c, v rt ^I' rr G o -u ro > N ro 0- ro _- ro ro tr C3 O ro LO m C1 .-• ro rt rt N N �^ � II II II II II II It C Ln �•' C)_ \ n o N r (n u1 -P' ° ns w m 7 ,C� N m O O O Cr, C) N r'r nJ ipr a0 0 0 0 • N z. 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