HomeMy WebLinkAbout018-1002-00-000 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
SW' jSW--,S1,T29N—R17 W 27CONVENTIONAL F-1 ALTERNATIVE State Planl.D.Number:
Town of Hammond ❑Holding Tank ❑ In-Ground Pressure L:%ound (if!TT200677
110th Avenue
NAME OF PERMIT HOLDER! ADDRESS OF PERMIT HOLDER: INSPECTI N DATE'.
Duane Van Someren Route 2, Baldwin, WI 54002 f0 .I -- $$ 30
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: JCSTREF.PT.ELEV..
Name of Plumber: JMPIMPRSW No County Sanitary Permit Number:
Dale E. Hudson 6629 St. Croix 106087
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED'.
1-1 YES ❑NO DYES F-1 NO
BEDDING: VENT DIA.'. VENT MAT[ HIGH WATER NUMBER OF ROAD'. PROPERTY WELL: BUILDING:JVENTTLOEFRESH
ALARM FEET FROM LINE. AIR INT:
DYES ONO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING'. LIQUID CAPACITY JIUMP MODEL PUMP;SIPF/ON M A NUF ACTURE" WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
1:1 YES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF JPHOPEHTY W LDIN(i I VENT TOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES NO NEAREST
SOIL ABSORPTION SYSTEM.Check thesoilmoistureatthede thof lowln tENUTU
JOIAF M TEif IMATI HIAL AND MAHKIN6
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM: _
£ WIDTH. LENGTH INO'O'E", DISTH PIPE SPACING, COVE" INSI OE OIA -PITS LIQUID
BED/TRENCH TH NC MATERIAL' PIT, DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH UISTR.PIPE UISTH PIPE DISTR.PIPE MATERIAL NO DISTH NUMBER OF is PROPERTY WELL. BUILDING'. VENT TO FRESH
BE LOW PIPES ABOVECOVER EtEV.INLET ELEV END PIPES FEET FROM LINE AIR INLET.
NEAREST-
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
OYES 1:1 NO
SOIL COVER ITEXTURE PERMANENT MAHKFHS OBSERVATION WELLS
_ El YES ONO OYES I--]NO
DEPTH OVER TRENCH BED DEPTH OVFR TRENCH BEO DEPTH OF TOPSOIL SODUFIf JEE OYES MULCHED CENTER EDGES ❑YES. ❑NO ❑NO OYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
f WIDTH. LENGTH NO.OF LATEHAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
i MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO UISTH DISTR.PIPE DISTHIBUT ION PIPE MATERIAL&MARKING
ELEV_ ELEV. CIA ELEV. PIPES DI A..
ELEVATION ANDI
DISTRIBUTION
INFORMATIDN HOLE SIZE HOLE SPACING DRILLED CORRECT L COVER MATEHIAL VERTIICAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO 1:1 YES ONO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS NUMBER OF PRIOE ERTV WELL: BUILDING:
FEET FROM
❑YES ❑NO ❑YES ❑NO INEAREST-
Sketch System on Retain in county file for audit.
Reverse Side.
TITLE.
DILHR SBD 6710 (R.01/82) SIGNATURE'. Zoning Administrator
DILL-IFS SANITARY PERMIT APPLICATION COUNTY' �D1,
In accord with ILHR 83.05,Wis.Adm.Code 5
STATE SANITARY PERMIT�!J�,#
[�m
-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. .5? -QOM 7'7
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES N NO
PROP^ER�TY OWNER PROPERTY LOCATION
G 4l.,12 `i r�✓ Oi/?ef y 5 t1 %5 W%, S / T- N, R (or W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMB R BLOCK NUMBER SUBDIVISION NAME
• L- /
CITY,STATE ZIP CODE PHONE NUMBER 71 CITY NEAREST 11 ROAD,LAKE OR LANDMARK
f r ❑ VILLAGE: fj/C!/// D � //V- �l✓
II. TYPE OF BUILDING OR USE SERVED: `-' -1111• d/P-IDDaZ -�O-
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify):
/Y7/
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. ❑ New b.,lal 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.�3Conventional b. ❑Alternative c. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e..r Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a.,o Seepage Bed b. ❑seepage Trench c. ❑ See a e 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): �y
Private ❑Joint ❑ Public
Feet 141
VI. TANK CAPACITY Site
in aIIons Total ##of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank Ozy) i5)00 �e <
i Lift Pump Tank/Siphon Chamber Z10 ❑ ❑ ❑
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:
71:5 l - 7,
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
FZ10 Z_
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
o �
CST's ADDRESS(Street,Cit State,Zip Code) Phone Number:
l so x l- n l co I;rr lC); ��-�OD 7� G�''
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial l charge Fee
Adverse Determination ae.eke
X. COMMENTS/REASONS FOR DISAPPROVAL:
Pllqkl 0#114)44,-d
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:
1. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
I!. 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;
VI. 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 a//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 8Y2 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 de:)ate. The groundwater bill Ground 8t8r
included the creation of surcharges (fees) for a number of regulated practices which Wisco
0
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r>wa ure
is used in your building is returned to the groundwater through your soil absorption o r
system or the disposal site used by your holding tank pumper.
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- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
=DD-6398
• 4
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 inadequaoies 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 �� r '. ✓�_`
Location of Property 't-0 k Section , T `! N - R W
Township
Mailing Address �-
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) ? Yes No
Volume 7/ls and Page Number e�/.O as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. -Land Contract
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.
3 .- - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTV OWNER CERTIFICATION
I (we) cuLU6y that a t statements on thi6 601m ane tnue to the but o6 my (oun)
hnowtedge; that i (we) am (cute) the owneh.(6) o6 the ptopenty descAibed in tUA
.in6onmation 60nm, by vi tue o6 a waAAanty deed Aeeonded in the O66.iee o6 the
..County RegiAten. 06 Deed6 aA Document No. /., �—, ; and that I (we)
pnesentty own the gkoposed bite bon. the sewage dizpoSEE76ystem ion I (we) have
ob.tai,ned an eaAement, to n.un With the above de6cxibed pnopenty, bon the
Con.6tkucttion o6 said system, and the same has been duty necotded .in the 066.iee
06 the County Regi6ten o6 Deed6, as Document No. )
t`Z,z`z
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
aD
DATE SIGNED DATE SIGNED
I� DOCUMENT NO. ` WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
Iq
STATE BAR OF WISCONSIN FORM 2-1982
403698
II-_ --- _ - . . ._=._ ._ . ..._.._ . REGISTERS OFFICE
David L. Anderson and Glenda M. Anderson,
ST. CROiX Co., WIS.
�! ..-husband- and w -f e.-... . ......_--....................................
ReC'd, for Record this 22nd
------------------------- -------••-••--•-•----•- ? day of July u_ 1.� �85
-•------------•-------- ------------••............----•-•--••-
- --------------------------------------------•---•-------...-------•-----------------••••--••••-•---
8:30 A r M
conveys and warrants to _Duane---L-.---VanSomer.n and._D ane_-L.
VanSomereD_, .•hsu_1 ___gild._yy� e�...�1 .--loznt••tenants
... ---•-••-------•-------•----•----------------•--••---.._......--•---......••..... ...••--....... hOhlr of Ga.Of
:
.� .... ..............................................................................................
.... .... ....................................................................................................... ' RETURN TO
......... -------------------------........................................_............................
._........
the following described real estate in St:_ __
__Croix_ ..... County,
.....
State of Wisconsin:
Tax Parcel No: ......................
Part of the Southwest Quarter of the Southwest Quarter of Section 1 ,
Township 29 North, Range 17 West described as follows: Commencing
at the Southeast corner of said Southwest Quarter of the Southwest
Quarter; thence West 362 feet; thence North 515 feet; thence West
100 feet; thence North 550 feet; thence East 462 feet ; thence South
1 , 065 feet to place of beginning.
i' SFEA
,00
EE.
This This ls- --
---------------- homestead property.
(is) (is not)
Exception to warranties: liens and encumbrances of record.
�I
u Dated this ...._._.....
................ ................... day of -•-•------•-------J-uly---...--------...---•---------------...., 19...85.. i
I
(SEAL) ................... --------------------- -------------- .
(SEAL)
. David L. Anderson
------.....-•-••---•-•--•--- ..............—.................... -------------- .............
David L. Anderson
----•----•-•......-•-•-•.........(SEAL) -------------------------------------- -----------------------------(SEAL)
* Glenda M. And
Glenda M. Anderson
AUTHENTICATION ACKNOWLEDGMENT
I; David L. Anderson and
Signature(s) ____________________________________________________________ STATE OF WISCONSIN
Glenda M. Anderson ss.
------------------------- -----------------------------------------------------
..................................... County.
au nt
. _.icated this -.-^day, of------July------------ 19_;.s Personally came before me this ................day of
... 1----------------------------------------------
-------------------•-•••......-••--•---- 19-------- the above named
. Gr g
e o A. Timmerman
-•---------------------------------------------•------------------------------ ---------•-------------------------...------------•----------------------------- i
TITLE: MEMBER STATE BAR OF WISCONSIN j
(If not, ............................................................ .................•-•authorized by § 706.06, Wis. Stats.)
to me known to be the person ............ who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Gregory A. Timmerman
Baldwin, WI 54002 ------------------------------------------------------------------------------
---•........................................................................... Notary Public County, Wis. i!
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
j are not necessary.) date: 19.........
ii
!` *Names of persons signing in any capacity should be typed or printed below their signatures. i
STATE BAR OF WISCONSIN
KcMUlarcompnry nn FOAM No. s— 1982 Stock No. 13002
En
H
9
ST C - 105 r
r
H
SEPTIC TANK MAINTENANCE AGREEMENT c
St . Croix County z
C
9
OWNER/BUYER
ROUTE/BOX NUMBER J /f_ Fire Number
� y ,. .
CITY/STATE r_�1r` (.t?�/i /�T'/ +. LIP %:_
PROPERTY LOCATION:= t� '�, -� f' �y, Section T ZV N , R /7 W,
Town of St . Croix County,
Subdivision—A Lot number.
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 pit 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 m_ y be eligible to receive a I 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.
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 Depart-
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Office within 30 days
of the three year expiration date .
SIGNED
DATE ,4 _ / 9 `Sy
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 .
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&,BUILDINGS
INDUSTF, ', DIVISION
LABOR HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090)& Chapter 145.045)
LOCATIO •S SECTION:T ,1 TOWNSHIP/MUNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME:
�L.t) '/aw'/a 1TZ9N1R )?�(or qm N/4 N� Al
(AUNTY: OWNER'S B ER'S NAME: MAI LING ADDRESS:
Sf Goo.' 7)uahG r Z �.u,' i' 5400
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: I PROF S: TESTS:
Residence 7 x/ ❑New Replace I _ _ �� // / _ O
RATING:S=Site suitable for system U=Site unsuitable for system l (p Q
C E]ST(IOONAL:IMOUND,:( IN-GROUND-PRESSURE:IsEIS YSTEM-IN-F-FILLrE1S ,M9 :1 OLDINGTANK RECOMM END EED SYSTEM:(optional)
❑S 2U 2S ❑U ❑S L�1U , '"20,41Ial
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: ��j Floodplain,indicate Floodplain elevation:
F PROFILE DESCRIPTIONS
BORINGI TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH h OBSERVED EST,HIGHES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- y,5 9 ,'7 p X110 2,f �S 13 -d• ��'' S,"l �. .
JG e/ /
B- 3 5:g3 B� t / 'Bl ;�• /�" �s�� �" /'e5,� �D"l3nc
B-
B-
41 04
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 PERIOD PER INCH
P- Z ,O 61 �� 'i
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 101, 4105
_ __..
3 € I
e A i I
f
_ _ __ _ _
�_ ITN
i ,
i
4
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 F— TESTS WERE COMPLETED ON:
�Q1e Nu on //- � - Pr
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST SIGNATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
be a complete and;accurate soil test,your report must include:
1. t,�)inplete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
1 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. fv1AKE A LEGIBLE diagram accurately locating your test locations,Drawing to scale is preWred.'A
S:!parate sheet may be used if desired;
8. lv';ike sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
9. C,mplete all appropriate boxes as to dates, names,addresses,flood plain data,percolation test exemp
tion, if appropriate;
10. i' i he information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box;
11. in the form and place your current address and your certification number;
12. Ise legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED'WITH THE"
')CAL 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 - Sandstone
gr - Gravel (under 3") LS - Limestone
*s - Sand HGW - High Groundwater
cs Coarse Sand Perc - Percolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is - Loamy Sand > - Greater Than
*sl - Sandy Loam < - Less Than
*1 - Loam Bn - Brown
*sii - Silt Loam BI -- Black
Silt: Gy - Gray
*ci - Clay Loam Y Yellow
sci - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc -- Sandy Clay w! — With
sic - Silty Clay fif - few, Fine,faint
xe Clay cc _ common, coarse
pt -- Peat mrn - Many, medium
rn - Muck d - distinct
p - prominent
HWL - High water level,
Six general soil textures surface water
for liquid waste disposal BM - Bench Mark
VRP - Vertical Reference Point
TO THE OWNER:
This -ail test report is the first step in securing a sanitary permit.The county.or the Department may request
veriti-ation of this soil test in the field prior to permii issuance. A complete set of plans for the private
sewn= ! system and a permit application must be submitted to the appropriate local authority in order to
obtaie a permit. The sanitary permit must be obtained and posted prior to the start of any construction.
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PAGE -3 OF�.
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
•---VENT CAP
4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING
_
�: 25' FRCM DOOR,
JUNCTION BOX MANHOLE COVER
'
WINDOW OR FRESH 12"MIU.
AIR INTAKE
GRADE I
40 m1m.
COIJDUIT �— —
18"MIN. �\\ ----------
C�YcJ PROVIDE I
INLET �JE�P4E AIRTIGHT SEAL
n j1o����
APPROVED JOINT A tv, I I I APPROVED JG I W
W/C.Z. PIPE I I ( W/C.I. PIPE
EXTENDING 3' _ E`P�tONS I III ALARM EXTENDING 3'
ONTO SOLID SOIL. � IAN I II ONTO SOLID S01
B
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0 f
T pN1 � GE I
D cJ�E G
D�R��� �N PUMP--, J OFF
CONCRETE BLOCK
RISER EXIT PERMITTED OIJLH IF TANK MANUFACTURER HAS SUCH APPROVAL
SPECIFICATI0NJS
SEPTIC AND
DOSE TANKS MANUFACTURER: >ees NUMBER OF DOSES: PER DA5
TANK :,IZE : _ Z60 GALLONS DOSE VOLUME: /-34-'8 GALLONS
ALARM MANUFACTURER: . t5- c/ CAPACITIES: A=S ,1 1KICHES OR `'Z 7,Z GAL L0U5
MODEL IJUMBER: _- Me✓'G C/rV B= ,s2� 4 INCHES OR 31 1� GALLONS
SWITCH TYPE: _ ale✓' C u v-V D C=rl•9 INCHES OR 3GALLOIJS
PL.IMJ' MAAILIFACTURER: r0 Lt 3�6 _ D= Z- INCHES OR tj'ALLOUS
MODEL NUMBER: 1416 03 L, NOTE: PUMP AND ALARM ARE TO BE
SWITCH TOPE: __ I�'I e- _ur,/ INSTALLED ON SEPARATE CIRCUITS
PUMP DISCHARGE RATE 700 Z GPM
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION UTION PIPE.. 2 "0._ FEET 888
-I- MINIMUM NETWORK SUPPLY PRESSURE . . . . . , . . . . . 2.5 FEET
+ -? FEET OF FORCE MAIN X FjpFTFRICT1oN FACTOR_. ' y9 FEET 7/1
TOTAL DYNAMIC. HEAD = /Z- FEET
INTERNAL. DIMENSIONS OF TAIJK: LENGTH / / ;WIDTH 7/ �
. TH ;LIQUID DEPTH /
SIGUE D: ��t /YG�IX�dv�� L.ICF-KJSE NUMBER: M P 4c< 3-19-U
DATE:
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
y 796-2239 (HAMMOND)
425-8363(RIVER FALLS)
-° HAMMOND, WI 54015
I
March 28, 1988
Division of Safety and Buildings
Bureau of Plumbing
P. O. Box 7969
Madison, WI 53707
Dear Sir :
An on site investigation for the Duane Van Someren property
located in the SW 1/4 of the SW 1/4 of Section 1, T29N-R17W, Town
of Hammond, revealed suitable soils at a depth of 36 inches,
below which high groundwater was noted .
This site should be suitable for a mound system.
Should you have any questions regarding this subject, please feel
free to contact this office .
Sincerely,
Thomas C. Nelson
Zoning Administrator
rc
QFPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&.BUILDINGS
DIVISION
INDUSTRY,
CC
P.O. BOX 7969
LABOR AND
HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON,WI 53707
(1-163.090)& Chapter 145.045)
LOCATION:,c SECTION: Q n TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
SLc) 1/4Gr)1/ / /T� / �/R ) /I(or qm AU N4 ��
COUNTY: OWNER'S B ER'S NAME: MAILING ADDRESS:
Sf /x 7),alo(f 2 Cr-C12• flt, 13 w," i' 5400
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROF R PT ONS: PERCOLATION TESTS:
Residence r/ ❑New XReplace
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
❑S 2u 2Sau El SDu 0S NU 0S ER
If Percolation Tests are NOT required DESIGN RATE: If an portion of the tested area is in the /4//under s.H63.09(5)(b),indicate: � /v1 I Floodplain,indicate Floodplain elevation:
F PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH lilt, ELEVATION OBSERVED EST.HIGHES TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
� /YID
/ AIh I R. `
B- / 1.5 �'7�?0 d� Q �� ''f�/si/ /� ''13 • z`f ' s,'l r, .
met
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- l 2.0 o +2. �O 3 .� 3
P- Z 1p
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 /a
,
;
tNi
__ .
F.
1,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): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
be a complete and accurate soil test,your report must if'ICIL :le:
1. t .,mplete legal description;
2. 1 le use section must clearly indicate whether this is a residence or commercial project;
1 t.iAXIMUM number of bedrooms or commercial use planned;
4. 1'; this a new or replacement system;
5. (.:)rnplete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
" THER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. N -EASE use the abbreviations shown here for writing profile descriptions and completing•the plot plan;
7. r.'AKE A LEGIBLE diagram accurately locating your test locations..Drawing to scale is pref, rrecl. A
st=parate sheet may be used if desired;
B. ;t<;ke sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
9. % ,mpiete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp-
1, )n, if appropriate;
10. i the information (such as flood plain,elevation)does riot apply, place N.A.in the appropriate box;
11. m the form and place your current address and your certification number;
12. ske legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE"
I,".)CAL 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 — Sandstone
gr — Gravel (under 3") LS -- Limestone
*s.- Sand HGW — High Groundwater.
es Coarse Sand Perc — Percolation Rate
med s — Medium Sand W — Well
fs — Fine Sand Bldg Building s• - __.:
i
Is Loamy Sand ) — Greater Than
*s1 — Sandy Loam Less Than
*1 — Loam Bn — Brown
*sit — Silt Loam BI Black
si — Silt Gy — Gray
*ci — 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
in — Murk d — distinct
p — prominent
HWL — High water level,
• * Six general soil textures surface water
for liquid waste disposal BM — Bench Mark
VRP — Vertical Reference Point
TO -1 HE OWNER:
This >il test report is the first step in securing a sanitary permit. The county or the Department may request
verif -rition of this soil test in the field prior to permit. issuance. A complete set of plans for the private
sewa,;,, system and a permit application must be submitted to the appropriate local authority in order to
obta a permit. The sanitary permit must be obtained and posted prior to the start of any construction.
T. •
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