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HomeMy WebLinkAbout020-1190-10-000 � I o �r c 00 °-) ! N o d ,o c d ! ° I d U 0 A N Q) c j w a� I a � I z c .- L m c LL O 3 v E Q 0 I Cl) Z H Z � � a m N F- In c O O Z a c � r y v Z .O M N m y N y a C a 30 L O c p m o d c w Z m D o N Z d N R E O ZZ O H •+ J Q N V C ay C p m O O d L m 53 a cn o z 3aaa C IL c •iV � 0 N y co co cn J U rn rn Z -0 a voa � a� N 3 E > m N a `p v d Q in ca b Co N N �+ O L M N C E p N Vi CD 0- l(') m O E CO C 0 W N ! U Fo C) c o 0 r w C M v'LO N M y Z fl- 0.0 p C N O 7 _ N O N O R U •c^l �,i O N S � � � O Z C F- � (n U EL d a CL E O A ciaz; oinu j t Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S4 Ali���s� TOWNSHIP ���30�� SEC. Z/ T N-R�� ADDRESS X41al ,boy "�a fZST. CROIX COUNTY, WISCONSIN SUBDIVISION �4co5^ � �; .�3p LOT y LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM or-fLi c, ll I d t J1 r _ _ `w 13 i t m � 28 �o _l 1 AAA i INDICATE NORTH ARROW i BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: /Q 3.0 Proposed slope at site: g °moo /Vo,y ti SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: _ Tank manhole cover elevation: Tank Inlet Elevation: �O"� Tank Outlet Elevation: Number of feet from nearest Road: Front,Side,O Rear, O /3y� feet From nearest property line FrontWSide10 Rear,0 �zo feet Number of feet from: well 1,E) building: (17 froYN 5E �a�fh (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE r ' R�K PUMP CHAMBER Manufacturer: if 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: �o s � .`r1 4 / Trench: �-- Width: /Z ' S ' Len$th: 4 Number of Lines: -- Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, Ft .('00 Number of feet from well: Z' Number of feet from building: �g (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: 0 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, O Ft. Number of feet from well: Number of feet from building: Number of feet" from nearest road: Alarm Manufacturer: I Inspector: Dated: Plumber on job: n-rr c, ,r►- ,J•�! sj License Number: M P 3/84:mj J t DTEP"TMkNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS ON I LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVISING P.O.BOX 7969 MADISON,WI 53707 State Plan I.D.Number: SW4,SW4,S21,T29N-R19W CONVENTIONAL 1:1 ALTERNATIVE (tale Plan I. Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot @ 9acobs Landing NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Miller Route 5, Hudson, WI 54016 `_7- Z— //.Co 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 //�4-r./ Doug Strohbeen MP5432 St. Croix 112653 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES 1-1 NO DYES ONO BEDDING. VENT DIA. VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING.JVENTTOFRFSH ALARM. LINE. AIR INLET FEET FROM DYES ONO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING'. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED'. PROVIDED. DYES ONO ❑YES ONO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA L NUMBER OF PROPERTY JWELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) 1:1 YES ❑NO NEAREST SOIL 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. COVER INSIDE DIA -PITS LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH IDISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PR OP ERTV WELL BUILDING V NT TO FRESH BELOW PIPES ABOVE COVER. ELEV.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 OF SYSTEM 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 ITE%TURF PERMANENT MARKERS OBSERVATION WE ITS ❑YES NO DYES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES. DYES 1:1 NO —]YES ONO [:]YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL N0 DISTR IDTH.PI PE DISTRIBUTION PIPE MATERIAL&MARKIN(; ELEV.' ELEV, DIA.. ELEV.. PIPES D . ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS CAL LIFT CORRESPONDS TO APPROVED ❑YES El NO DYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING- F/ FEET FROM LINE /7 El YES 1:1 NO DYES 1:1 NO NEAREST /�/►j �erv�ar/Gt/ � �. ��.? d 3 ._ 297 Sketch System on � Retain in county file for audit. Reverse Side. SIGNATURE. TITLE DILHR SBD 6710(R.01/B2) Zoning Administrator SANITARY PERMIT APPLICATION COU 51L HR In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# C0t_0 —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 15K NO PROPERTY OWNER PROPERTY LOCATION 'L ,E�Kw�4 W14, S.4+. TZ/, N, R / E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME wJ on `I m a CITY,STATE ZIP CODE PHONE NUMBER ED CITY NEAREST ROAD,LAKE OR LA DMARK ` O 3S 7 VILLAGE: t, 14-mr-60or i`�GtJ 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family --3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. New b.El Replacement c. El Replacement of d.El 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. 19Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. tZ 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): io IS" 4 V8 Ao Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in oallons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed —::P— F-1 Septic Tank or Holding Tank 000 Lift Pump Tank/Siphon Chamber ❑ ❑ V11. 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: .001� 51"'a k bQ�c q Z �-*-� M P- !'Sl 3 Z ( Z47) 3Z,3 r' Address Street City,State Zip Code): Name of Designer: Plumbe'r's ( y, p ) 9 Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# D" K; 5 C 4. `i,tom e h a✓..So CST's ADDRESS(Street,City,State,Zip Code) Phone Number: /1/ 4 L a.C-emi Aut. 4 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial It Surcharge Fee Adverse Determination X. CCOOMCMENTS/REASON�S�F�O"R DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc:.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property 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 buildirg 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; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'42 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�alat9t' included the creation of surcharges (fees) for a number of regulated practices which Wisco tn`$ a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasurei is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. ! o 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) a` 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 perms* issuance. Should this development be intended for resale by owner/contractor, ("apf- 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 t Location of Property,. 5„kJfi, Section Z�y_, T Z-Z N - R ,�17 Z 1� t Township Mailing Address Ate/ Jfa.� Z�"Z- ■„ Subdivision Name ��cC?,�.s La��sc+�.d�s /J7 f"�0 ■ T Lot Number ` , 1� �t k p Previous Owner of Property Lo,i-C; Total Size of Parcel �_ .o j Date Parcel was Created � I Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? - Yes No Volume D and Page Number -L.1•-■-- as recorded with the Register of Deeds i i 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 Nap, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) eeAti.6y that att 6tatement6 on thiA 6onm one tn•ue to the beet o6 my (oua) knowledge; that 1 (we) am (are) the owner(e) o6 the Pkopeh ty de cA i.bed in th.i e .in6onmai,ion 6onm, by vtAtue 06 d wahnanty deed neeonded in the 066ice o6 the County Regieten o6 Veede ae Voeument No. 3.5-4/ / 7 ; and that I (we) pxeeenitCy own the p..opoeed 61.te bon the Aewage &Apo4ac eptem (on I (we) have obtained an eaAement, to hun with the above de6cAibed pkopenty, bon the conAtaucti.on o6 said Aptem, and the same has been duty teeonded in the 066.iee o6 the County RegieteK o6 Veede, aA Voeument No. `� 3 s'�//7 ) . i SIGNATURE OF PILMUR SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED I oOCUMEPAI NO. WARRANTY DEED TNIa aPACK agagngo Fan MCOODlNO VATA STATE BAR OF WISCONSIN FORM 2 I , REG� 435417 ti.. a�o coo Cost vFin bed for ReWd Virslttia.M.. Naa$Pne A single women. . . .. ..... ........... . It , ..... . .. . . ........ ... .. .. .. ... ......... . ..... ... .. ........... .. .... 8:00 AM . . . .. .._. .....I . ..... . . ...................... . .............. conveys and warrants to .. :SAm..E. Miller,..a..single man... .............. a ....... .. . ... ...... ..... . .. ........ ..... ...... . ... ......... ...... MMR 00� . . .. ......... .._. ......... . . .. .......... . .... .... ........................ . .......... ............ . .... .... .. .... ..... ... .. ... ......... ................. .. ........ . I........ ... .. . . .. .... RETURN TO the following described real estate in .....-St. Croix ...County, State of Wisconsin: TaxParcel No:.............................. West Half (W1g) of the Southwest Quarter (SWk) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the public highway and except Lots 5, 6, 7, and 8 of Certified Survey Map in Vol. 6, Page 1747, Docii No. 419479. That part of the West Half (WIS) of the Northwest Quarter (NW%) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. EEF This .. .As..not.......... homestead property. #Ii1It (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. _.. , I9.88 .. Dated this %v` day of . . r.0 ........... ... .......(SEAL) [J.l ��es�K� i// .iS's'-V..ISEAL) . .......................... .................................. ... a .Virginia.M...Hanson..... ...... . .(SEAL) .(SEAL) A17THNNTICATION ACENOWLEDtiMSNT Signatnre(s) ............................................................ STATE OF WISCONSIN ............................................................................... a. S. ..�.ry.�1L............Countq. authenticated this ........day of........................... 19...... Personally came before me this ...°... ........day of ........f hIA.n L................. 19.8,8... the above named ..........................................•----................................. Vir inia M. Hanson •........................ ..................................................... ................................................................................ TITLE: MEMBER STATE BAR OF WISCONSIN ................................................................................ (If not.............................:............................ authorized by 5 708.06.Wis. Ststs.) .... .. ................ ... ..... ........... .... . .... to me known to be the perpon ............ who executed the foregoin trument and iAnowledge the same. THIS INSTRUMENT WAS DRAFTED BY ttQ#�$.Ar..MW1')'gY.,..Heywood,,,Cari._b.;Murray.... P..Q....BRx..229,..HudgAih..1 1....54016.......•-•--...... !��ota•. uric p -. .:.. (r. .. County, Wis. (Signatures may be authenticated or acknowledged. Both My Co mV ent.(It not, state expiration are not necessary.) date: *XanM of persons signing in any capacity should be typal or printed hr-low thr it Pignntu.res. WAaRAX T DEED STATE BAR OF WISCONSIN rl'isronsin IA*al 111ar.4 I•... lo.• FIRM Na a— 19%2 WI.. _ 1 I ' H x N H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County x d a H OWNER/BUYER M ROUTE/BOX NUMBER _Fire Number -� .CITY/STATE-/ &X.to l•[J .,� ZIP /� PROPERTY LOCATION: SU-) 16, Section _z / , T_�E N, R_-,�W Town of A_/113oYl , St . Croix County, SubdivisionSatp6,s 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 pdt into the system can affect the function of the septic tank as a treat- :rent stage in the waste disposal system. St . Croix. County residents may be eligible to receive a 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. 0 • E I/WE, the undersigned , have read the above requirements and agree H to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources . Certification form must be completed Nd returned to the St . Croix County Zoning Off:Lre within 30 days the three year expiration date. SIG Nf!,� J L DATE 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. INDUS'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, 11 CC DIVISION HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 3 07 (H63.090®N) &Chapter 145.045) LOCAT SECTION: TOWNSHIP OT�NO.:BLK:NrO. SI �I N NAME: or tW 1/4 U '� I �Ta9 N/p/q f( ,/r COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: I• ero,,c > IBS s'lle4z 14 0L 1~1C &J. &46 t O USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIP PROFILE DESCRIPTIONS: ER A ION TESTS %Residence 3 : PQNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system 's-40 r ONVE—NT—I NAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optiona) ZS ❑U ®S ❑U �S ❑u ❑S ©U ❑S Du If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the A under s.H63.09(5)(b),indicate: g I Floodplain,indicate Floodplain elevation: /`/w!/4 P FI E DESCRIPTIONS BORING TOTALS DEPTH TO GROUNDWATER4N6FI4S CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTHf`A. ELEVA 1 101, OBSERVED EST. IG/H_EST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) Q B' / i CCl, /07, ! I r 70m h r -s'/. ! C5- ..5: Pal S. B- 2- 174' /009.0' o,uC Zot Gn s/ 3 CS o?,�-BnS IV B-3 .6' /67. 3 ' Alo. ,o' , 7 Oft a i­ s/ . 3 4.1 c B- Y 7.0' U y., A &,4,1 e— (-Q / s 60,40 /• G S B�,S IO CS B-s 70 10 y y s Ido�u ;> 7,P Y AA .-s/ a r c S S B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PERIOD 3 PER INCH P- o 9- 6 G C -< 3 P- Z/ 16" O Z, P- 3 .3' o Z co 3 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 /03, ---------- u ` i _ E l a , _ 1 Y, l 3 I ; Y` G iOrCS�..I �G C �o ; . _._ r qfe // grow,. B rO I-lfl,iu f 04V ��.�`�°�R/ 4Q t /1e- .,c MGs I,the uni tei re i t the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrates Card ,gh a data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: yL�cf t �� ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST TUBE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — INSTRUCTIONS FOR COMPLETING FORM 116 - SBD - 6396 To be a complete and accurate soil test,your report must include: 1. Complete 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 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. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet:may be used if desired; B. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. Complete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp- tion,if appropriate; 10. If the information (such as flood plain,elevation)does riot apply, place N.A. in the appropriate box; 1 1. Sign the form and place your current address and your certification number; 12. Make 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 Sail Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cola Cobble;' (3- 10") SS - Sandstone gr - Gravel 'under 3") LS --- Limestone *s - Sand HGW - High Grauridwatei cs - Coarse Sand Perc - Percolation Rate med s - Medium Sand W - Well fs Fine Sand Bldg - Building Is Loarny Sand `j -- Greater Than 4sl - Sandy Loam < - Less Than *( - Loam Bn -- Brown sil - Silt Loam BI Black si - Silt. Gy - Gray cl - Clay Loam Y Yellow sci - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles se - Sanely Clay wr' - with sic - Si4y Clay fff few,fine, faint fe *c Clay cc common,coarse pt Peat nirn - Many,medium rn - Muck cl -- distinct p - prominent HWL - High water level, Six general sail textures surface. water tot, liquid waste disposal BM - Bench Mark VRP -_ Vertical Reference Point 0 " r ' 1 � i TO THE OWNER: This soil test report is the firs`step in securing a sanitary permit. The county or the Department may rerluest Lie;if icatiorr of this soil test in file ficid prior to pert-nil issuance. A complete set of plan:, for the private srw ;!r> systent and a permit application must be submitted to the approp6aie local aut,hc si,y in order to obtain a pcitrtnt. The san:tary pertnit mus', be obtained and posted prior to td f `tart of any construction, a _^� i Ix � e� � -� �`moo� �� W X10 c, t /� a y r ` l b op it .. � o to IV o h a d 3 1 4 M 1F s p "A p, N r... LJ*j. 1 6, P 4 i tr P N u► • j ,b � � 0. 1 •t �L�T�fol�+� •rZ:• r