HomeMy WebLinkAbout040-1206-20-000 AW
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
l
OWNER KAU CW Ian TOWNSHIP rleO_ _ _ SEC. I T�LN-R_iLW
ADDRESS G IUV e fZ r��!�IJ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION QOV 2 R StP 1 obi LOT Io� LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHF. 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/8x53 4en
W 50 `IS loot'°n
s
l9'
INDIC TE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
y '
Elevation of vertical reference point: 1y0.() Proposed slope at site:
SEPTIC TANK: Manufacturer: wu"L Liquid Capacity: 1000 4A)
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: � .y�._ Tank Outlet Elevation: 4s . ` 7 `
Number of feet from nearest Road: Front, Side Rear, O I T� feet
From nearest property line : Front 10 Side,0 Rear,0 6 feet
Number of feet from: well Not N , building: 1
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
w
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,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan). 5�'°t . I ao }{ep°°'. VY0 " U.yb
4u vu
w la() �_N fa
SOIL ABSORPTION SYSTEM 91
9.90
Bed: Trench:
Width: Length: _ Number of Lines: 3 Area Built: 9 5
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear Ft . 5
Number of feet from well: Mot IN
Number of feet from building:
(Include distances cn 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, 0 Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
q �l Inspector:
Dated: �C�N y I IV Plumber on job: CSLvrno 2`
License Number: 3 7 1
3/84:mj
DEPAI�fMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
DIVISION
LABOR&HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
P.O.BOX 7969
MADISON,WI 53707 State Plan I.D.Number:
NW 4,NE 4,Sec. 16 ,T28-R19 (If assigned)
❑ CONVENTIONAL ❑ ALTERATIVE
Town of Troy.Lot 1 Holding Tank ❑ In-Ground Pressure ❑ Mound
H L ADDRESS OF PERMIT HOLDER: INSPECTI N ATE:
Ray & Sand Galler �82 Southern Pacific Rd. Hudson Wl 5 01 '
BE H MAR Ikj.(Permanera reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: ST REF.PT.ELEV.:
Name Plumber:
'`
MP/MP No.: County: 0 Sanitary Permit Number:
Jim Boumeester 4304 St. Croix 1 8
SEPTIC TANK/HOLDING TANK:
MANUFACTUR R: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
o� t,� PROVIDED: PROVIDED:
S 6 J q t I e I .AYES ❑NO ❑YES ENO
BEDDING: VENT DIA.' VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY BUILDING: VENT TO FRESH
(,] I I ALARM: FEET FROM lit LINE:q p�' AIR INLET:
El YES�NO I 1 ❑YES�NO NEAREST—► I`f a' I
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPAC TY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: ROV DEDLABEL pROVIDED:OVER
YES ❑NO ❑YES ❑NO ❑YES ❑N -
GALLONS PER CYCLE: MP N ONTROLS OPERATIONAL: NUMBER OF PROPERTY 7MATERIALAND BUILDING: VENT LE FRESH
FEET FROM LINE: AIR INLET:
(DIFFERENCE BETWEEN YES ❑NO NEAREST—♦
PUMP ON AND OFF
LENGTH: DIAMETER: MARKING:
SOIL ABSORPTION SYSTEM. Check the oil moistu at the depth of plowing FORCE
or excavation. (If soil can be rolled into a wire,const uction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: 4MAERIAL R INSIDE DIA.: #PITS: LIQUID
BED/TRENCH !-� TRENCHES: L PIT DEPT H:
DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPES DISTR.PIP MATERIAL: S . NUMBER OF PROPERTY W LL: BUILDIN : VENT TO FRESH
BELOW IPES: ABOVE COVER: ELEV.INLET: ELEV.E DJ� : FEET FROM LIN 0} AIR INLET:
0� �I 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;
ED YES El NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑YES ❑NO El YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM-
WIDTH: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 E__1 NO ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑YES ❑NO ❑YES ❑ O NEAREST—�
f
t s
\ i
Retain in county file for audit.
Sketch System on TITL .
Reverse Side.
M
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SBD-6710(R.06/88)
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05,Wis.Adm.Code COUNTY +
—. �.. .�. t . C90
STATE SANITARY PE I
-Attach complete plans(to the county copy only)for the system,on paper not less than _3 S
8%x 11 inches in size. Dc/_35 if revision o revious application
—See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION.
PRO?FPTY OWNER PROPERTY LOCATION
pN EK '/aN %a,S f TQaN, R J9 E(or)
PROP i�ia E R'S MAIL N DRESS LOT# BLOCK#
Sou A ROAD 10, 1 IVA
CI STATE IZIPCODE PHONE N MBER SUBDIVISI N NAME OR CSM N MB
{t ID 1 v 0
_0 CITY II. TYPE OF BUILDING:'(Check one) ❑State Owned ❑ VILLAGE j NEARE T ROAD
0 0� .�.0
❑ Public ER1 or 2 Fam. Dwelling—#of bedrooms 3— PARCEL TAX NUMBER( (�
III. BUILDING USE: (If building type is public,check all that apply) �� — I�U` !°���
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. XNew 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.) PROPOSED(sq.ft.) (Gal /day/sq.ft.) (Min./inch) ELEV TION
0 S fo 1ctf 3o I'+ 3 Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncre Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank — 0U�
Lift Pump Tank/Siphon Chamber.—L+ , El El n 1 0 n I F71
VIII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
Ti u f-R 3 8(6-Q^-,0
Plumg®Address(St_ r.01,city S te,Zip Cod ):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued ssuing Agent Signature(No Stamps)
Approved El owner Given Initial Surcharge Fee)
�� J� .o O lo-30-V
Adverse Determination "j
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 wili 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 mustbe 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 numbers) of
where the system is to be installed.
II. Type of building being served. Check only ohe and complete## of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for�tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115form; and F) all siting 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)
APPLICATION FOR SANITARY PERMIT
S T C - 1100.
This application form is to be completed iin full and signdd 'by the owner(a) of the
property being developed. Any inadequacies will only.reault in delays of the permit
issuance. . Should .this development",be 'intended'.'for:';resale by owner/contractor, ("spec
house") a! .•.... , , ... ., : +�.�. .�, tti! '1t;: ..:,;. .;;; •...7:,.. ..<.. ,,:. ..,,.,..
then a second form should'be retained and�completed'whe'n the property. is .
sold and submitted to this office with the appropriate deed recording.
— — — — — — — — — — — — — — — — — — — — — — - -- — — — — — — — — �— — — — — — — — — — —
Owner of.Property RAY AND.SANDY CALLER
Location of Property NW k NE , Section 16 ,• T28 N-R 19 W
Township TROY •
Mailing Address 3110 NEAL AVENUE
AFTON, MINNESOTA 55001' i .fr
382-
Address of Site XXX SOUTHERN PACIFIC ROAD %s,:i:.• '
Hudson, W:i scons i n :5'4t716JrrXa;a'r
Subdivision Name GLOVER STATION
Lot ar J ?a:Rcra `t 4,
Number 12 ;;,°. ,; `�,�' :;;•
*Previous Owner of Property C.M.AYE AND DENNIS R: SCHULTZ AS TENANTS IN COF".
Total Size of Parcel 2.02 Acres
Date Parcel was Created September 11, 1979
Are all dornera and lot lines identifiable? X Yes- No
Is this property being developed for resale (spec house) ? Yes _ X No
Volume _ 742_ and Page Number 71_8 as recorded with the Register,of Deeds..
• i
INCLUDE WITH THIS APPLICATION THE FOLLOWING: . , S
A Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Resister 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 Suivey Map, the Certilied'''S VM' Y Map shall also be required.
'PROPERTY OWNER CERTIFICATION
I ((Ve) CVLa6y that a t &tat
emer1,ts on thri,a : ,,... J;.,.,:� :;..`: .:.,:._ •:._:.:
lznowtedge; that I (we) am (ahe) .the. own eAkf ooh he..p op¢hty ee.6ehibed6�n th,i6 :�:7
'n6O mation 604m, by vi tue o6 a waAAanty deed nthe p4o in the 06t�.ice o6 the
Coin Reg.iaten 06 Veeds ab Document No. X13080
own a pnopos ed s.i.te bon-.the a ewag e d i,6 poa a ya ems (o dIthat I (we) pnea entzy
eaaement, to nun with the above dedcti.bed pnopeAty► bon the(eonatkucti,on o6 aai,d
system, and the same hae been duty heeohded to the 066
Deed4,., ice o6 the County Regten 06
ad Vocument No. 13080 V. c,a
S MATURE OF► ER ay Gal er -
S GNATURE OF CO-OWNER (IF APPLICABLE)�dY Galler
�DATA SIGNED '-2
DATE SIGNED
bo'cb ENT No. STATE BAR OF WISCONSIN FORM 1—1982 THIS SPACE RESERVED FOR RECORDING pnTP
WARRANTY DEED R"31IRS OFfiCe
ill ,l V,nu��I S ST. CROIX CO., WIS.
Rec'd. for Record this 9th
This Deed, made between ....C,_.M,_._Bye_and Dennis______________ duty of June A.D. 1986
R. Schultz, as tenants in ccnmlon f _... at 3:00 p , M,
.
- ----- -------------•--. ...........................................................................
Grantor, James O'Connell
--- .... •---•-• .-... . ...................................... . .,.V d�t
and.....Ray_.L.-_Gallen.and...S.ands_K.__Galler-,---------------------------------
husband_and wife, ------ --------• -------.. .--------- a? �-
---• UeP
- ------•--------- .............. ------- Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
_.. - -- -
[V- / Olx RETURN TO
conveys to Grantee the following described real estate in -..- �....--
County, state of Wisconsin: Ray L. and Sandra K. Galler
3110 Neal Avenue
Afton, IN 55001
Lot 12, Glover Station Subdivision, located in the Tax Parcel No: ...................................
NWa and N04- of Section 16, Township 28 North,
Range 19 West, Town of Troy, St. Croix (bunty, Wisconsin.
T,
i
This 1S not homestead property.
-(i4 (is not)
Together with all and
sin ular the,hereditament and appurtenances thereunto belonging;
And---.._.C'..M. -- ._e arlcl Dennis R_. Schuj_tz
........ ---- ---•------- --•------------------------'---••----...........
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
for easement, restrictions and covenants of record
and will warrant and defend the same.
Dated this .........7th........... day of ---------- - June............................. 19..86...
i
......•-"---' •---•................................_(SEAL) �� l--f! C _ ..............................(SEAL)
* C. M. Bye
•........................•----...-----•-••---•--•-----.......... . C.•- -----•--••-•...
.....................................................(SEAL) - Lk--- v
\ ' . •. ..... ............(SEAL) .
* * Dennis R. Schultz
....................... •---------•--•-•-----
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ............................................................_ STATE OF WISCONSIN
--------------------•--•-------------------------•----•---•-----------...------.
St. Croix ss.
...............•--•-•--•-•----County.
authenticated this ........day of........................... 19------ Personally came before me this .......Vt!?__day of
June ...__., 19...86. the above named
•--------------------------••----.........------------------....•--------•----•- Bye
-----------------------•----
* -Deririis-i�:-ScYitiltz----
--------------------------------------------•--------------••-•------••-----•- ............................................ ...................................
TITLE: MEMBER STATE BAR OF WISCONSIN _______________•_-- .....................
(If not, -------••---------------------•---•-•-• .................... ......-•--•'---•-----••-•--••---•---•----•--•-.....--•••-......---•-----•-•.....
authorized by § 706.06, Wis. Stats.)
to me known to te tAle-person 5......... who executed the
foregoing insjr metlnt and/1acknowledg the same.
THIS INSTRUMENT WAS PRAFTED BY 1 Q
C...M... _..Attorney at Law ... ...an :. Cb�by
-----------••--•-•--•-• Di,
P. 0. Box 167, River Falls, WI 54022 �•;..; .............
U'�L Y�oix
---.....................................�--------------------------------------- Notary,Puti11 �.......................................County, Wis.
(Signatures may be authenticated or acknowledged. Both My COTTPm tjoj ,permanent. (Tf not, state expiration
are not necessary.) ., 6f 88
date: ? ' '•r; ..1(. .....................9 19.........)
*Names of persons signing in any capacity should be typed or printed below their signatures.
QMB:dc
' STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St., Croix County
OWNER/BUYER RAY AND SANDY GALLER
ROUTE/BOX NUMBER XW SOUTHERN PACIFIC ROAD FIRE NO.R��ress
CITY/STATE HUDSON, WISCONSIN ZIP 54016
PROPERTY LOCATION: NW 1/4 NE /4, Section 16 , T 28 N, R 19.' W,
Town of Troy , St. Croix County,'
Subdivision Glover Station , Lot No. 12
Improper use and maintenance of your septic system could result in its prematu e
failure to handle wastes. Proper maintenance consists of pumping out the septi-c
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.
n•
St. Croix County Residents MAY be eligible to rece,.kye a .grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
P g Y, .
prior to July 1, 1978. St. Croix County accep�ed' this program in August of
. 1980, with the requirement that owners of ALL NEV'SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner• and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-sitq
wastewater disposal . system Is,jh proper operating condition and (2) after
Inspection and pumping (if necessary), the septic tank -is Tess than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal' system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form .must-6e completed and returned to the St.Croix County Zp ing ffice within
30 days of the three year expiration date.
SIGNEL
RAY GAL R E*R
DATE
St. Cr
oix County Zonin g Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
i
KttJUK I Viv ZiUI r I`9i_1Y%11VU0 HIN V
I'i%)I;STRI' � `�• `` /�•� � P.C) C').
,50P, AND ' /� j°�t.QSl.itJE� 1 ��iV I S.'�.J�I J (115) MADISO►�,
i`ircC:FJ Ry!ATIGVS -.i
(H6s.�9(1) & Chapter 15.045)
_ _ - 1
tt c� 0 51�-lei �TOVJN$HIP; UNICIPALITY: NO.:BLK NO.: SUBDIVISION NAME:
1 1 2u 1� --T---- —'---- - Z — GLoV
/ 1� /T N R E (r,t �_ Troy
C- MAILINGS ��r�r�ESS- 3�\� Ul. •4J� .
COUNTY: OWNE UYER'S AME: I
I ZZ �=- ►x Rh�t G:�LLE'R _ AKF` u 1 Z , h IJ
(— DATES OBSERVATIONS MADE
USE _..._.. ._._.__.._. "�
COMM R ALNE RIPTION: PROFILE DESCRTPTIONS: t:
'�ResidenceJNO.BEDRMS.:
� }v .� QNew 01`leptace
RATING:S-Site suitable for system U-Site unsuitable for system --
ONVENTIUNALrajE51
-GR UN�REIJI : STEM- N•FILL.HOLDING TANK:RECOMMENDED SYSTEM:foptional)
---
J
�s au osu__-asu _;atX ,� _`�____________.
(If Pe-.:at on Tests are NOT required DESIGN RATE: If any port ion of the tested area is in the J
under s.r163.09I5) S Ib),indicate: C L-•°c S Z Floodplain,indicate Floodplain elevation:
- PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER-INtMVS CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH-ft ELEVATION OBSERVED E 1 HE TO BEDROCK IF OBSERVED(SEE ABBRV.ON-BACK,)
B-- 1 8-b 7' 8- S ` - -
B- Z -7•y' 9Y.9 ti � �• y
-1...!
B-
- --_ ----
PERCOLATION TESTS
T DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t P I
P-
P-
P• •
P-.
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori•
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. 1N%--n Or 1. — .q 1-3 ' PA%-=.S li8 Z
SYSTEM ELEVATION "z'%''- 2-�m g 1•o r C RV-bT- SK MG
—
r— -- --1 q;
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I, the undersigned, hereby certify that the soil tests reported on this form were mode by me in accord with the pror.,tdures and methods specified in the Wisc•�,,s.n
,administrative Code,and that the data recorded and the location of the rests are correct to the best of my knowledge and belief,
/sa 4r' .._.,.. lily t io 1rr , ;Bi, 'i nurnn(,. 0. I)CrL\a•or replacement s..ysiern:he suitability rating be xQs. A SITE IS S!)I T APLE FOR A HOLDING TAI-4K ONLY IF ALL STEMS ARc RULED OUT SASrD 01,\ SOIL CONDITIONS:
s. PL EASE use the abbreviation! snovvr, here fPi tdriiinc; fV c• la peSCrit)tiortg 6{)ti GGr.
7 YAK E A LEGIBLE ei;;inr;1r11 8C.r t: t)i(';1 IG rlr ter?t UrArl:
.' -1\' Ih C'ilt Uln +r'r):7r lrr. 'i7C.bi.'Cr�� _) 'i•}�• •,.• r•::7 ., r. 'r•c � .
1. b° j ' r riYt{iJ; 1tt'+r.rl.:. . .. .�t •i rl. ..•r'• ri,•;raar'r(+nt
wit,
..r. apr,...prate' �:d rat! r_/;i.r•,r�.
1U. I` the information icucl,as floou r,iain,rtevatiar; d�• .s no: 1'up i. G.,CC• N.A. i;. :r �«\r.•:r{rti.:;' box;
11. Sign the form and Place your current address and yom certification. number;
12. Make legible copies and distribute_as.reduired. ALL SOIL TESTS h1UST BE'FILFD. VvITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOI-L'TESTERS
Soil Separates and Textures Other Symbols
st — Stone (over 10") BR — Bedrock
cob — Cobble t3 10") _ SS — Sandstone
9r' Gravel (under 3")_-.. .. .. _._ LS -_ Limestor>e
*s — Sand— HGW — High Groundwater
cs — Coarse Sand __
_ _ Pere - Percolation Fate
"
Wed s — Medium Sand
_ ....
is — Fine Sand`—
4ti Well
Is — Loamy Sind
Bid9 Build r
ny
sl — Sandy Loam_
— G r eater Than
_ I Loam — Less Than
_ _ ._.. _.
Br-t Brown
Y — •
sil — Sift Loan,
si — Silt
(7,
"cl — Clay Loam
scl Sa,uly Clay Loan,
sicl — Silty Clay Loam
sr, — Sb ,dy Clay
sic — S;:ty Clay
Clay
pt
F° - b'.rtrcal Rei=_=rctr'ct Point
70 THE OtNNER; ; .... t,•, ._ __ - - _ . ._. _._ __ ._. .._- � �. __.... -
1 '
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C adel Homes
DESIGNERS &BUILDERS
Lcf- r Z �c�v�tL �AT O"4
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3880 Laverne Avenue North Lake Elmo, Minnesota 55042 612 779-0671
C7Q L.G.�ll� I,
GLOVER
LOCATEDINTHE NW /4,AND THE NELA40FSE1CTMST28N,RMK
TOWN OF ,ST.CROM COUNRY,WISCONSiN
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80,
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Sys�er•
FRESH All), INLETS AND OBSERVknoti PUE
_ CI:OSS SECTION —_
--� Approved Vent Cap
Minimum 12" Above
Final Gr
ya l,;n ,
4" Cast Iron
Above Pipe"-;J Vent Pipe
To final Gradci-
Marsh Hay Or Synthetic Cove r 1.ng
Min. 2" A ga:cg'I;.� � ;,
Over Pipe �V V
Distributioi_ li I F-- Tee
Pipe _...._....__.l
�
j� Ome17 Aggregate Perforated Pipe Below
—� 13encath Pipe Coupling Terminating r
• �j. 3� --� • • � -_ ._ Bo L• tom of System
1
s�
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t , J
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N
TT`
1
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r �
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a i
r
r
z
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a � j
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(1-163.090) & ClliiPlet 145.045)
............ OT-NO 71 U B D I V f§1-0 WW'A—M E':
ON: TOWNSHIP! q:B[K-N5.1
/T2zSNJ� E 'W)
rj'i'F SS:--
OWNER'S BUYER'S a
NIFTO 1-Z .,j
• DATES OBSERVATIONS MADE
ff�
PROFILE D S 1p I IONS:101
IF
S
NO.BEDRMS.: COMMEA(I DESCRIPTION: RNew I_-Replace a
Residence
RATING:S-Site suitable for system U-Site unsuitable for system RECOMMENDED:1 COMMENDED SYSTEW(optional)
P�j U
OU I MS OU I `-s -
LnIS EA I EIS rLXLEIS
I' n of the le%lPd area is in the
DESI any port-on 1! P'e,rola-on Tests are NOT required Ficiodplain, indicate Floodplain elevation:
.ndet s.H63.09(5)(b).indicate:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROU D ATER-INtIFfEr- CHARACTER Of—SOIL wIfIT—THICKNESS,C(5—L6iR-, TEXTURE, AND DEPTH
TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.).
DEPTHtbg ELEVATION S Hl HE , , .-) Q -5.
i7U'll TEXTURE, AND 6--DE DEPTH
L
eL
77
I Ll"I
B. -7-L/'
IB- L4.9
B-
B. C?
PERCOLATION TESTS
—WATER IN HOLE TEST TIME DROP IN WATER EL-INCHES RATE MINUTES
TEST DEPTH . PER INCH
I
NUMBER1 INCHES AFTERSWELLING INTERVAL-MIN. P Ft I L)
P-
. ... ..............
P-
P-
P-
-P.
PLOT PLAN. Show locations of percolation tests, soil borings and the dimensions of suitable soil areas Indicate scale or distances. Describe what are the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surfacee elevation at all borings and the direction and per ent
of land slope. 1F.i t-n Pr
SYSTEM ELEVATION
r
r
zz:,=•
TQ
4—
Jos
•
2
L
7' Uj
7
Sul -1
—t4-
W x
L
SiE�C'm)lj 110
1, the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the pror•-tclures and methods specified in the Wisc,—s
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and be lief,
NAME print TESTS t6uFllPu-.TEDON:
Uffff—ES S: ';;t:T \4 '-ac'x CERTIFICATION NUMBER: PHONE NUMBER(optiz,-, "
Is
Sy I
SIGNATURE:
.0
-111S:RIBUTION- Original and one copy to Local Authority,Property Owner and Soil Tester.
011-HR•S80-6395 JR.02/82) OVER