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HomeMy WebLinkAbout020-1134-20-000 ( \ E _ « � G § \ / ■ � Mk & £B § . /f $ n§ } k° \ U01. mE\ k �j � Cl) � . , � « £ 7 w E 2 } § B z k 2 } . � _ ; , . ) 7 7 % e a ƒ f ƒ Q kmk }§ . § ) � 04 .. § R & ) 2 « . e , 2 a ■ c U . k n © k U) U) k / \ k U- 0 k § z a -� tI a a a « to & § = m 2 j v ' o § § ƒ § § 6 2 ) § § (D J 2 ( < \ \ m § U) U) 2 ® ¥ . \ a I E § 9 § \ } § m � o $ / & 2 2 £ ® � a § ® 7 2 ¢ f - § / } k / o } / k ) � ■ � J ) ' k IL IL E / kag k J � \ 0 2 2 Parcel #: 020-1134-20-000 12/07/2005 02:42 PM PAGE 1 OF 1 Alt. Parcel M 17.29.19.652 020-TOWN OF HUDSON Current I X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-MCDONALD, CHAD S&CATHERINE L CHAD S&CATHERINE L MCDONALD 908 RIDGE PASS HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): •=Primary Type Dist# Description `908 RIDGE PASS SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.300 Plat: 2624-WILLOW RIDGE 2ND ADD SEC 17 T29N R19W WILLOW RIDGE 2ND ADD Block/Condo Bldg: LOT 43 LOT 43 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 10/17/2005 809468 2909/411 WD 07/23/1997 1039/414 WD 07/23/1997 817/103 2005 SUMMARY Bill M Fair Market Value: Assessed with: 92524 324,600 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.300 60,200 270,900 331,100 NO 05 Totals for 2005: General Property 1.300 60,200 270,900 331,100 Woodland 0.000 0 0 Totals for 2004: General Property 1.300 30,900 223,700 254,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 119 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ^, /�n� ��p�p �y TOWNSHIP � �s� SEC. l9_ T Z N-R Zy W I ADDRESS �l2 `>""f1;�(/ ST. CROIX COUNTY, WISCONSIN SUBDIVISION !-U,�l��✓ ��t LOT `3 LOT SIZE PLAN VIEW 5 Distances and dimensions to meet requirements of I•IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r -- -' - ,Gy 8' f _ �Zy l- INDICATE NORTH ARROW op S7 � o ' 1 q r- BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: fplJ,� Proposed slope at site: _T^ SEPTIC TANK: Manufacturer: 6jf.e$_ Liquid Capacity: /O0e-) Number of rings used: 6 Tank manhole cover elevation: , yelp, 40 /09 .Z p Tank Inlet Elevation: Tank Outlet Elevation: /Q ADO Number of feet from nearest Road: Front 10 Side 0 Rear, feet i From nearest property line Front,O Side, eDRear,O feet Number of feet from: well >,� building: // (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,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: r Width: L Length: 5'9 Number of Lines: Z Area Built: Af'49� i Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft . 2 g r Number of feet from well: SD Number of feet from building: �6 r (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on fob: License Number: j�9 3/84:mj 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 State Plan I.D.Number: NF'a, NF%, S19,T29N-R18W CONVENTIONAL ❑ALTERNATIVE (If assigned) Town o6 Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATT JimlChtc" Cte-ments 612 4th StAeet #4, Hudson, W1 54016 9-a ff 4 "30 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David S. Fo ent i3289 St. Croix 112711 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER _ PROV DED. PROVIDED 20. "� YES ONO ❑YES KNO BEDDING. VENT DIA I VENT MATL.: HIGH WATER NUMBER OF IROAD PROPERTY WELL. IIIUIL1176. VENT TO FRESH AIR INLET ALARM FEET FROLIa�E DYES NO ` OYES NO NEAREST -" :J I DOSING CHAMBER: MANUFACTURER JBIDDING LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO : YES ONO EYES ONO GALLONS PER CYCLE: PUMP Al D CONTROLS OPERATIONAL. NU—MB EROF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ONO NEAREST SOI L ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING 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 NO.OF DISTR.PIPE SPACING COV F„R INSIDE DIA 1t PITS LIQUID BED/TRENCH -+ TRENCHES M 'rERIAL: PIT DE PTIi DIMENSIONS r ! 4 +-r.•.s' GRAVEL DEPTH FILL DEPTH IDISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO. R. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIIP S ABOVE C �ER. ELEV.INLET ELEV.END'. �) �J f YJt PIPE FEET FROM LINE,IJ ') / O fytf AI L'�� l6 y /('/ NEAREST--► ••( J{•T/ 6/4 ff 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. DYES ONO SOIL COVER TEXTURE PERMANENT MARKERS OfiS EHVATION WE LLS El DEPTH ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED IMUICHED CENTER EDGES El YES El NO OYES ONO DYES El NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER 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 INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES El NO 1:1 YES NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE El YES ONO ❑YES 1:1 NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIG * � �.r� y �•-.* TITLE � DILHR SBD 6710(R.01/82) Zoning Admimi.6traton L :7:=1j7 SANITARY PERMIT APPLICATION COUNTY L7 ^D/ ke In accord with ILHR 83.05,Wls.Adm. Code STATE SANITARY PERMIT## /10 '-7 i/ —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 D NO PROPERTY OWNER PROPERTY LOCATION S T , N, R E (or -OFIOPE)(TY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SrBD�VISION/NAME —A a3 ✓v i //CAW !c J CITY,STATE ZIP CODE PHONE NUMBER C3 CITY NEAREST ROAD, ryel VILLAGE: TOWN OF- II. TYPE OF BUILDING OR USE SERVED: 000— Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): 111. PURPOSE 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. 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. 0,4eepage 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): p'J �,� 4?�� 34 OCi O Feet 9 rivate ❑Joint ❑ Public VI. TANK CAPACITY ##of Prefab. Site Fiber- in gallons Total Manufacturer's Name Con- Steel Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete glass App. Tanks I Tanks strutted Septic Tank or Holding Tank 0 Y ----------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) ,MWMPRSW No.: Business Phone Number: ,rl Sr PI er's Addr as(Street,C , ip Code): Name of De ' er: VIII. bbiL TEST INFORMATION e ''ed Soil Tester CST## 133 et,City,Sta ,Zip Code Phone Number: © (7 I ART T USE ON LY KKVV ❑ Disapproved S nitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) EApproved ❑ Owner Given Initial / Zv charge Fee `] Adverse Determination 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. A14 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 31 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; 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 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; Vlll. 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'/2 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 Ground Atar included the creation of surcharges (fees) for a number of regulated practices which Wisco fni.,iS can effect groundwater. The surcharge took effect on July 1, 1984. All of the orate thaF buried rie sur 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. a The monies collected through these surcharges are credited to the groundwater fund admini4;- ° tered by the Department of Natural Resources. These funds are used for monaor ,g grourd-- f water, grow--water contamination investigations and est;,blis'-irnent of stwidards. Ground, at •r, it's worth protecting. SBD-6398(8.03/86) 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 J0,Me_S (2hr i'5+i ne C l men+s Location of property 6 W 1/4 S W 1/4, Section , T 2q N-R_J3 W Township Q -� fj LAs0,) Mailing address 708 4'1dQf; Po-G.5 540 11'o e1.1 kP-�eN'! . & /.-2 (-/`F'` dy--�/U :r06 Z/ way'50'j' W-Z S¢0/6 Address of site 908 1S d E' J0'2!55 /7 ud s", W -1 'ES �0 � 6 Subdivision name Wi' ( loc.v Lot number Z/3 Previous owner of property _/�- 95erZe16en anA Virg1'nl4. '-i3er' el Sen Total size of parcel " 1-5 �9C,2'�-'5 Date parcel was created ( q`1`l Are all corners and lot lines identifiable? _Yes No Is this property being developed for resale (spec house)? Yes No Volume 2 1 '7 and Page Number 103 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. ------------------------------------------------------7--------------------- PROPERTY OWNER CERTIFICATION 1(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. ' 1 9 5 7A ; 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 County Register of Deeds, as Document No. ) , Signature of Signature of Co-Owner If 9 ( Applicable) " 1q, 19 W Fe DA-e--o—FrSignature Date of Signature L Td K 817 PACE 103 DOCUMENT NO. WARRANTY DEED II THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 I REGISTER'S OFFICE A.R. Bertelsen -- k a Arnold R. Bertelsen and 'I ST. CROIX CO., WI ;I _-_Virginia-.A.--Bertelsen, his wife Reed for Record •-----------------... I �i - -------------------------- ------- ---- JUL 19 1988 conveys and warrants to James_-R.-_Clements._and Christine j qt �/Q P M II J_ -C1ements.,..husband_-and w-i_f.e, _.as_ mar-i-ta1...pr0_per-ty ii with—rights--oi--sux-ri.voxsh.ip... .............................................. - II Register of Deeds I" -----------------•-•-----------------------------•----------------------------------•---------" .....................__.__________.__._.._.._.____...._ ------- RETURN TO ------------------------------------------------------------ I the foll owing described real estate in _.._._ St_--Croix ............_----------County, - -- ; State of Wisconsin: Tax Parcel No: ------------------------------ Lot 43 Willow Ridge Second Addition to the Town of Hudson, i I� I FED �I I i I li li I � II �I I� II �I This _,___is not - homestead property. (is) (is not) Ij � I Exception to warranties: fiEasements and restrictions of record, if any. Dated this ------19th--------------------- day of -------July---- -------... - 88 �I ------------------------ 19---- /��.-tom I (SEAL) -- - (SEAL) I ------------------- -------------------------------•-------------- l_d__R_,._Bertelsen w --------------__-------------------------------•----------------(SEAL) �� - (SEAL) Ij �I --------------- * V-i-rgJ-i-mia- A.---Be-r-t-e.Lseen--------------------•--- -•------------------- ij AUTHENTICATION ACKNOWLEDGMENT Signature(s) ------------------- STATE OF WISCONSIN �i ----------------------------•--------------------------------------------------- ss. St. Croix - - Cr County. authenticated this --------day of___________________________ 19...... Personally came before me this 19th ---------------day of II i --- July , 1988____ the above named ----------------------------------•------------•----•-----' A.R.. Bertelsen a/k/a Arnold R. i his wife ------ TITLE: MEMBER STATE BAR OF WISCONSIN ---------------------------------------------------------------- ------------- ---------------- authorized by § 706.06, Wis. Stats.) I to.4be known to be the persons------------ who executed the " "fOtegbmg.instrument and acknowledge the sa e. THIS INSTRUMENT WAS DRAFTED BY ' 401 •�"" At-torney ai--•Law_, �r ' 5401fz , r�, Croix " "Notary�ublic '---- ---- -------- -------------County, Wis. gvle �rMd�$oth� ('� La�i.�o ---- -----•--p--------------(------ _, 19--------- (Signatures may be authenticated or ackno o#imission is:permanent. If not state expiration are not necessary.) , I' Names of persons signing in any capacity should be typed or printei�beiPpy„>,ij�jt+SSgnatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 2— 1832 �l ee. Wis. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 070 m e 5 IQ c`em P'OYs ROUTE/BOX NUMBER NO. 90 CITY/STATE ,L/ud 50"J; w T ZIP v5401lb PROPERTY LOCATION: 501/4 �/6 Q) 1/4, Section _ ) 7 , T ;?'/N, R�W, Town of )144d.soto , St. Croix County, Subdivision Wi' lJouj EJ2& , Lot No. q 3 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. �y SIGNED ( It c1► tii�p� C,� DATEt 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 I >t � DEPARTMENT OF. REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR HUMAN NDLATIONS PERCOLATION TESTS (115) MADISON WI 7969 (H63.090)& Chapter 145.045) LOCATION: . + SECTION: TOWNSHIP/ *Pd - LOT NO.:BLK.NO.: SUBDIVISION NAME:ITg N/R/J (q4 COUNTY: OWNt'R"S BUYER'S NAME: MAILING ADDRESS: USE 9 7,7 1? DATES OBSERVAT ONS MADE LJRe 1V NO. COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence � ew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system / T/ CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) CAS ❑U CaS E CAS ❑U 112S ❑U CAS ❑U 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: �'^ I Floodplain,indicate Floodplain elevation: 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.) / I i B- B- S , 00 6. � o �..� ,8 s s. 13- gr- 6- I S i PERCOLATION TESTS lye'* TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- P- P-_ 4�t V o 1. re, 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 _ ,_ .___ . i i ! E M_ 'T t I 7 E `1AF Sfi __ _ E r i 1 t P�r E ( E , # E t I E t i � ? 4­ -k- A. . ......�. ' I a ......L__ _ orted on this form were made by me in accord with the procedures and methods specified in the Wisconsin location of the tests are correct to the best of my knowledge and belief. TESTS WERE COMPLETED ON: ° 7 ♦ j Tester & Plumber CERTIFICATION UMBER: PHONE NUMBER(optional): Heights Road CST SIGNATUR WISCONSIN S023 one 7493686 ocaI Authority,Property Owner and Soil Tester. —OVER — ^ m � " * � � INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To bnaromplece and accurate Sail test, Your report Must include: 1. Complete |nDa} description; 2� The use section must clearly indicate whether this is residence oroommo,cia| project; 3. MAXIMUM number of bedrooms or commercial use planned; 4, b this o new or replacement system; 5� Complete tho 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, MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A aupmneewheet may te used ifdesired; 8. Make »uroyuur benchmark and vertical o|owmdon reference point are clearly shown,and are permanent; B. Complete all op:op,imte boxes as to dmcns, nomu'nddrnssos. flood plain data. percolation test exemp- tion' if appropriate; 10. If tile information (Such as flood piain, elevation)does not apply, place N.A. in the appropriate box; 11. Sion the form and place your current address and your Certification numba,; 12, K4eko legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil 9eparau:vmnd Tovmms Other Symbols a — Stone (over 10'') BR — Bedrock oob — Cobb|a (3 10'') SS — Sandstone g, — Grawe| (under 3^) L3 — Limestone °s — Sand HBW — HiqhGnmndwmxr m — ComrseGand Per — P�ny|ahunRmtm medo — Medium San(] VV — �"'|| Is — F|nu 8and B|dy — Building |r — L^mmySand Greater Than °d — Sandy Loom ( — Less Thai,, °| — Loam 8n — Brown °oi| — Silt Loom 81 — Black oi — SU| G — Grny ~d — Clay Loam Y — YcUmw y:| — Sandy Clay Loam R — Rod sid — Silty {]ay Loam mot — Mottles *o — SandyC|uy t � sic — Silty Clay fh — fmm' fine' faint °o — Clay cc — oommon' onme P1 — Peat mm — ma^v, medium T11 — Mock d — distinct p — prominent HVVL — Hiqh water level, ° Six Onncra| smU textures su face Water for liquid vvuotmdisr"osa! 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