Loading...
HomeMy WebLinkAbout020-1126-60-000 0 � > c 0 $2 m CD zi C cc (D —0 W- LL c C13 0) cc '0 Go 0 2 . — 00 tm CD 0 —0 c E Cc ce) w E z 0 z CY) w v) 0 z ca U 2 a)c 4 z E ED N m a) (D ID 0 co CO 0) c (�D I .2 \ mz0 (D 4.; z -!2 041 0 -a E (D w > cc CL c R MO) > 4) r- CL o m cc U) U) U) E EL E - 6�1 o 0 o 0 CL CL CL t \ -1 00 U) 00 co (n 00 CD 0) C -J ca 4= (D C'4 r a 0 E 5 2 a) :3 (L A V LM co C,4 U) E cis LO CD 0 q? 00 0 IL m CD Lo Co 0) co co 40. C14 0 r z 0 a) 0) 'n L� r.- 0 C.4 t-: C�! CD LL z co CL L: CL CL i v E 0 0 o J CL U) L) Parcel #: 020-1126-60-000 11/10/2005 08:09 AM PAGE 1 OF 1 Alt. Parcel#: 17.29.19.582 020-TOWN OF HUDSON 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 ROBERT W FREIBERG O-FREIBERG, ROBERT W 452 GREEN MILL LA HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): "=Primary Type Dist# Description 452 GREEN MILL LA SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.730 Plat: 2272-PARK VIEW ESTATES SEC 17 T29N RI 9W PARK VIEW ESTATES LOT 1 Block/Condo Bldg: LOT 1 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 812/120 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.730 63,500 151,500 215,000 NO 05 Totals for 2005: General Property 1.730 63,500 151,500 215,000 Woodland 0.000 0 0 Totals for 2004: General Property 1.730 32,800 134,700 167,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 136 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 TOWNSHIP _ SEC. LZ T 27N-R Zr W ADDRESS f s ,/'/� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT / LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM (A 0 i I 36i r oa \ ` l INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used a Elevation of vertical reference point: /fie Q Prop ed slope at site: Z_ SEPTIC TANK: Manufacturer: L�!���C1 Liquid Capacity: f T' Number of rings used: 19 Tank manhole cover elevation: Tank Inlet Elevation:&,SZ. Tank Outlet Elevation: jZ Number of feet from nearest Road.: Front,O Side,O Rear, O > 527 ! feet - • From nearest- property line Front.0 Side 10 Rear,0 y S 0 feet Number of feet from: well &gLe, building: 2 7 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 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, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 1/ Trench: Width: L Length:��— Number of Lines: Z Area Built: �z Y Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, 0-Aear,0 Ft ._rg� _ Number of feet from well: X�IJIG Number of feet from building: (Include distances' on plot plan). SEEPAGE PIT Size: Nianber 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 I� Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: I Elevation of inlet: Number of feet from nearest property line: Front, O O Side, O Rear, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• Dated: All 7ZZE Plumber on job: License Number: 3/84:mj DEPA TMENY OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 MADISON,WI 53707 BUREAU OF PLUMBING $ ,N>t%;S17,T29N-R19G1 )6�CONVENTIONAL ❑ALTERNATIVE I te Plan I.D.Number: Town a Nuctson assigned) {) ❑Holding Tank ❑ In-Ground Pressure ❑Mound Lot 1 Pa)Lkv ew B�Statu NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION DATE. Bob F,%abelcg 215 S. McNight, St. Paul, Mn ` �$ $• 3�� BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.EL V.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No Cnunry. Sanitary Permit Number Dave Pogenty 3289 St. CAoix 112793 SEPTIC TANK/HOLDING TANK: - ° MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER �D p PROVIDED PROVIDED w ter" V" `� .a 0 �.jb ES ❑NO ❑YES NO BEDDING: VENT DIA.: VENT MATT HIGH WATER NUMBER OAD: PROPERTY WELL: BUILDING: VENT T FRESH C. ALARM FEET FRO +y L NE IAIR INLET. DYES NO ❑YES C�PJO INEARESTF=�R [V1r/✓] :lV�1[�) IF DOSING CHAMBER: MANUFACTURER. __JgE 1-11-11 CnPACI TV PUMP MODEL JPUMP SIPHON MANUV AC711E1 1.VARNJING LABEL LOCK ING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑N EYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF, PHOPEHT WELL UILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) EY ES ❑NO NEAREST' SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I E N( TH IDIAMIT111 11111,114 Hlnt AND AH wG or excavation. (If soil can be rolled into a wire,construction shall cease until FORGE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: - WIDTH LENGTH NO OF DISTR PIPL SPA(JN(� COVER JINSIDE DIA 'PITS LIQUID BEd/TRENCH I THENCHES �I + NIA TERIAL' FIT DEPTH DIMENSIONS '11 AVECD PTH FILL DEPTH UISTH PIPE DISTN PIPE DISTR.PIPE MATERIAL NO DI NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH B LOW PIPES ABOVE COVER EI EV.INLE{ ELEV END /� ) PIP S LINE JA INLET: I` 41 1 C7" 1 NEARESTO-----o+ 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- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ .SOIL COVER TEXTURE 1ANI NT VnHKE HS JOBSE11VATION WELLS _ DYES ❑NO _❑YES ❑NO DEPTH OVER TRENCH 7DEPTH OVFH TRENCH REU DE PTR OF TOPS(1IL SODDED SEEDED MULCHED CENTER GES ❑YEs. LINO ❑YES ONO DYES 1:1 NO PRESS URIZED DISTRIBUTION SYSTEM: QED/TRENCH WIDTH LENGTH TRENOCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO UISTH DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING °.ELEV. ELEV. DIA ELEV. PIPES DIA.: ELEVATION AND'. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY 17ATIHIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES 1:1 NO DYES FIND COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF? PROPERTY WELL: BUILDING. FEET FROM. LINE. t1 DYES 1:1 NO ❑YES El r\ _ NEAREST q v a 0 ti a gti Sketch System on 1 Retain in county file for audit. Reverse Side. IGNATU TITLE. DILHR SBD 6710 (R.01/82) Zaw%ng Adm%nusra fan SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code kU / k D I L H R STATE SANITARY PERMIT# i/a —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 r� 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE El YES I •rNO PROPERTY OWNER PROPERTY LOCATION '/4/N '/4, S * T , N, R E (orAP PROPERTY OWNER'S MAILING A RESS LOT NUMBER BLOCK NUMBER SUBDIVISIO NAME CITY,STATE ZI CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK ❑ LLAGE: II. TYPE F BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOOSEE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. [?/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. L9A conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ee a e 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): " j `/;j Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site Fiber- Exper. Plastic in allons Total #of Prefab. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strr cted Steel glass App Tanks Tanks Septic Tank or Holding Tank ❑ ❑ Lift Pump Tank/Si hon Chamber 11 ❑ ❑ ❑ 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 St amps) 4#P/MPRSW No.: Business Phone Number: 0___ Plumber's Addr ss( re t,City State,Zip Code): Name of Designer: Vill. SOILYEST INVORAirlION Ce 'ied Soil Tester4pW)Name CST# �.33 Cgrs RESS tre ,Cit ,S e,Zip Code) Phone Number: Gt O� 1 G IX. C6UNTYtbEPAATMENT USE ON Y ❑ Disapproved Sy Permit Fee Groundwater ate Is g ' g(Agent bign�ature(No Sta s) dL' 1� \ Fee Approved El owner Given Initial F (►� ( ,O V rcharge Adverse Determination r 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. Athkevisions•to.,this permit-must;be approved by the permit issuing authority. A new permit may be needed if there is a change in your buildhg plans,'system Ic)_cafion, estimated wastewater flow (riumberof bed- rooms, etc.), depth of.system, or-type of system; . 4:` Charrges in'owner'shi`p°or plumber requires a Sanitary Permit Transfer/Renewal Form (SEND 636g) te°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 xi6ei} d ;" pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contactyour 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. Prcaerty owners 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; 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, gertification 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 8X2 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; wetly; 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 1`5 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 d'e'bate.-The groundwater Bill prpund &t included the creation of surcha ges (fees) for a number of regulated practices which WiscOrtsEn' 4 can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure:... is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. c 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. SBD-6398(R.03/86) n APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------=--------------------------- ------------------------- Owner of property R 0 Q E RT E&/8 E G Location of property tJ L' 1/4, Section —Z:, T v MR_Z�W Township 17()1)-50/V Mailing address Address of site `��.� ✓.�i�, , l Subdivision name f9�KU Lot number Previous owner of property Yo u SCl4OL Z Total size of parcel /, 7S Date parcel was createdn, ag.T4976 Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house)? Yes _ X No Volume , ;�>.-and Page Number ,LLB 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. 9 3 7 �9`S; 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 o th'at Reg' ter leeds, as Document No. ) . Signature of Owner Signature of Co-Owner (If Applicable) 'JeP4 11, j. Date of Signatur'd Date of Signature I� !MIS SPACE RESERVED FOR RECORDING DATA II DOCUMENT NO. I WARRANTY DEED i ;I STATE BAR OF WISCONSIN FORM 2-1982' f { 43 - _Li__ =l = REGISTER'S OFFICE ST. CROIX CO., WI DOUGLAS R. SCHOLZ, a single man, Grantor Rec,d for Record i MAY 27 08 conveys :.nd warrants to ROBERT W. FREIBERG., a.single.,man, - _ !I O1 2:�50 PM V �.C+wvtJf JL Grantee. I � ftqlsw of Do*& the followint; described real estate in St..--0T-01 X. . ........... .. County, State of Wisconsin: Tax Parcel No- -------- -------•------------- I, Lot 1, Park View Estates in the Town of Hudson. TRANM • a I I II I� I TOGETHER WITH AND SUBJECT TO easements, reservations, restrictions and right-of-ways 'II of record, if any. i I;1 This is TIOt homr.,tead property. Exception to warranties: i Uatcd this �t sa day o: May 1988 II (SEAL) 7L �'(/✓', - ��' ISEALl DOUGLAS R. SCHOLZ (SF.ALI (SFALi II i AUTHENTICATION ACKNOWLEDGMENT l Signature(a) ................. STATE, OF WISCONSIN 1 I; &S. ......-----•..----•-.-------•-.--•.•............................................ ST.. CRO-IX---.-----_.--- ..County. ` !� authenticated this ........day of........................... 19....-. Personnl1v came before me this dac of .... ..... ......... ..... 19...8$- the above named ...................................................... ............. - • ..................................................... Douglas R. Scholz _. ... ........_.. _._ . .... --.... _ TITLE: MEMBER STATE BAR OF WISCONSTN •• (If not. .......................... - avthorired by § 706.06, WIR. Rats.) to me knmcn to he the n••r,nn yin executed the foreirnintu• instrument -Ind ackn4'My' fllii sanfe? THIS INSTRIIMENT WAS DRAFTED flV 4�tt9r>i€y.Barry. C. Lundeen_ nt GILBERT, NfUDOE; P(j]kTEk--&•I,tINDEr-t. �w-..►.\ \� 1.................................econd Street,--•..........dson, Wisconsin �,,,,,,.., hllhti/ •'x rol'ntl TV S (Si¢naturex may he a tithe.ntiented or arknowlodced. Roth ',twni•• inn it nei•ninn•-,I l i nn:.':<t:to I ;I. r•ition are not nPCPVRRrv.) pi ) •Nams of DBTDnnn %irniow in any eanacitV I- tc.,,,t ., .,•...I �, Ih '• -.¢.-. �- WARRANT! DEED ATA'fE nmt or RTce%`'-V N: •, . 1 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1\©,BE(R ) G ROUTE/BOX NUMBER 1 V_U/ FIRE NO. / CITY/STATE 71���o/V J I SCOV S f V ZIP 9 I�(0 I �O PROPERTY LOCATION: 1/4 N 1/4, Section -7 Town of U DSOAl , St. Croix County, Subdivision TlJ1L_!1 V 1&J 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 Ive" St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address s l DEPARTMENT OF REPORT ON SOIL BORINGS AND yes SAFETY& BUILDINGS INbUST^RY, X35 f DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON,WI 53707 (H63.09(1)&Chapter 145.045) LOCATION SECTION: TOWNSHIP LOT NO.:BLK.NO.: SUBDIVISION NAME: 5E °/4x �� /T,� N/R 'E (or � COUNTY BUYER'S NAME: MAILING ADDRESS: �' . \ � I Dc.�h lyre � �, C'4•� USE ATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PR FILE DESCRIPTIONS: PERCOLATION TESTS: OResidence 3 -- PNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) CAS DU El DU 0-5 DU 12S DU I CJS DU L d 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: Floodplain,indicate Floodplain elevation: ,v PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B t P• 7 7 r i B- B- B-3 •s s B- ! L S �(ln ' 7' 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 PER1003 PER INCH P- 3 s P- N P- . S� P P s c 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. „� 3 SYSTEM ELEVATION tN I I � { E a 3 ._ _ ._ i t- - E _. T i 3 I ( F t 3 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. N (print): TESTS WERE COMPLETED ON: W CA s l 'f ADDRESS: CERT ICAT ON NUMBER: PHONE NUMBER(optional): ,G 1 3 — TO D6 C IG RE• DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — ~ ~~ ' ' . ~ ' \ \^ INSTRUCTIONS FOR COMPLETING R30K0 115 ' SBD 6395 ^ To beamompl an0mor�p,mead| tmx.vou, report must in�udr: ' � l Complete legal description; 2� The use section must clearly indicate whether this is residence orcommercial project; a, kUAX(K8Uh0 number of bedrooms orcommercial use p|anned; 4 b this a nmmor replacement system; 5 Complete /he*uimbi|hy rating boxes, A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 8� PLEASE use the abbreviations shown hv,e for vv/izing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately |ocadng you, test locations. Drawing to uoa|e is preferred. A sepanausnem may be used if desired; 8� Make owe your benchmark and ve,tics| elevation reference point are, demr|yshov,n'and am pormunanz; Q Comp|etn all appropriate boxes as to dates, numew'addmssas' flood plain data. poron|adon test exemp- tion, if appropriate; ?O |fIhc in formal ion (Such as f|nod p|uin'e|ovotion)does not apply, p|aoa N,A, it) theapprnurintobox; �1 �gn1heformand place your' Current address awl you, certification number; 72, fvlakr |w0ib)e copies ancl di*ribmf� as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHOR|TY WITHIN 30 DAYSOF COK8PLET|O§. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS ^ Smi| Separates and Textures Other Symbols � — 'Ione <ovor lD''> 811 — Bed od/ on (3 10^) 8S — Sondotono y/ — Gmvc| ,under3'') LS — Limestone Sand HGVV — High Gnmndvvate/ m — Coal se sand Pwc — Porco|adonRate meua — �mdiumSund VV — VVeU Fina8and 6Ng — `3ui|ding LoamvSand Gmate, Than �»| — 3andy Loam / Than ~| — Lomn` Hn w^ °m| — Gi|t Loom B — 8|ank �i — S,i11 Gy — Gey C|uyL�mm Y � YnUmn sm| — SandvC|av Loam R — R°d oid — 8i|tyC|ey Luum mut — mcx/�ns sc — Sandy ("ay fine' fmint °c — C|oy cu — oommvnusuza mm — ry 1a^v' modAum p — nmmino"� HVVL — High mmwr |mm|. ° Six gone,a| woi| texrues su v�r , ro/ UAuid waste dinposa| BM — Bench KAnrk' YRP — Veuioo| Rafe/enuoPoinr ' TQTHEOW0ER: is ooi| t�� mVo� is zbn � in� a oanhaw perm�� Tho county or-the Depanoenmuyrcgun�Th fnu m� vc//ficodon of thin Soil zn�>t in fi';|d prio/ to pu,mit issuance. A comp|ote sot of for tho u,i"ute mwogm mmmm an� a un/m�t um,|iva['� n ba oubmhtmj to 11"a arp,oprime |uoal autho,itv in order to oLuain a purmic Thn nmnimry pormu mu,�;t beubuammJ and posu* miorto he mart ofanr congmuion, I i w i . e i � n 0 ; O rn O ` :C" W ` SIC tx VN W� � o - i - i Iv N h N � F OF REPORT ON SOIL BORINGS AND S 3S SAFETY& BUILDINGS PERCOLATION TESTS (115) P.O. BOX 3707 ? .[,A rIONS � MADISON,W 1 53707 (H63.0911) &Chapter 145.045) 9 ii"'err SE TON: TOWNSHIP LOT NO.:BLK.NO.: SUBDIVISION NAME: �� i,7 /T,z N/R �E (or - j t U ER'S NAME: MAILING ADDRESS: d-M Q7 DATE OBSERVATIONS MADE NO,BEDR COM R DE C IPTIO : ��}! 1 Orb€ L S: TfSiS: 'New Replace - ------I IN!1: S-Site suitable for system U=Site unsuitable for system i i IOtJ^I MOUND: IN-GROUND-PRESSURE: STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) �. [JU! ❑S ❑U 1A ❑U ©'S 0U EJS ❑U ���SL ;.�' A,zo//Z —. :, i.;•i•,ir f e;rs are NOT required DESIGN RATE: If any portion of the tested area is in the r 0 W:1.09(5)(b),indicate: I I Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS lii1�I P H TO GR UNDWATER-INCHES CtIARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTIi gErt U[Fiil IN, ELEVATION gSERVED ES GH TO BEDROCK IF OBSERVED (SEE ABBRV,ON BACK.) f. 7 ke. %1 WA A ' > S.' F ' ' ' s oC I '. a Z "t:It/s gas �7' PERCOLATION TESTS WATER IN HOLE TEST TIME DROP IN WATER L VEL-INCHES RATE MINUTES AFTER SWELLING INTERVAL-MIN, PER100 1 PERIOD 2 p PER INCH Abe -� tit :v : rhjm%v locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori : •-i ,r•rti::il elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent :R I I'M ELEVATION 9S. _ARE_ WA 0- _.fir _ -- --- „ p rvnur,rl, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wi-ronsin �i"r:•.ri.n Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. jC ESTS WERE COMPLETED ON:Ad E RT FICAT ON NUMBER: PHONE NUMBERIolrrinnarl 1 1 .1 � 36 s C IGN RE l W_-. S q o�-3 - r 17 Ints: ": iginal and one copy to Local Authority,Property Owner and Soil Tester, _ (R.02/82) -OVER - d �� f Sri • •s � �' y i �