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HomeMy WebLinkAbout020-1190-20-000 ~ e \ � / _ / § g )V } f [ \0 §\ ! $ }i ) 2 ] ( 0 � I 7f/ � � n i 4i I \ \ E & / \ IL c ! E k § / 2 \ \ \ \ N ? : § M j } ƒ \ }_ R k 2 \2 = j . k = t k £ ) ) i 0 ~ 2 CLk2 ( 0 » & 0 2 / \ \ % a 33 , _ K ■ C ° k Ik 2 a 2 .� § & _ 0 2 j q } /_ ƒ \ ! ® 75 !Z!! = � \ \ § _ / E @ j . CO a � 0 ) ■ is ■ 3 ° S � % / / k U') LO § §\ E � I $ 75 j -� 2 ) ) ±r $ c n j Q z S \ \ ) / / ) \ 2 � EL � I — ' - 2 " IL CL / J a o U) J Parcel #: 020-1190-20-000 12/20/2004 04:12 PM PAGE 1 OF 1 Alt. Parcel#: 21.29.19.1193 020-TOWN OF HUDSON Current F ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *= Current Owner * DWAYNE D& NANCY L DAUGAARD DAUGAARD, DWAYNE D&NANCY L 815 HARBOR VIEW RD HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *815 HARBOR VIEW RD SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 3.0 Plat: 2133-JACOBS LANDING 1ST ADDITION SEC 21 T29N R19W SW 1/4 LOT 10 JACOBS Block/Condo Bldg: LOT 10 LANDING 1ST ADDITION 3.089ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-29N-19W I i Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 836/560 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 49233 281,000 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.089 30,500 186,900 217,400 NO Totals for 2004: General Property 3.089 30,500 186,900 217,400 Woodland 0.000 0 0 Totals for 2003: General Property 3.089 30,500 186,900 217,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 124 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 - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP 4�,/OG� SEC. Z/ T N-R.-L1=��/ ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE z. ( b¢c�✓� PLAN VIEW Distances and dimensions to meet requirements of I•1, HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Sy ,s 5 I/y'` = 10 J v �° �I h d 3 F�z A I L I I\VI r — w�I ----f st ti W saKfik I V iINIJj0'fiE NORTH ARROW y .< 7 BENCHMARK: Describe the vertical reference point used I a as of 5 ,� core Elevation of vertical reference point: Yposed slope at site: - Z SEPTIC TANK: Manufacturer: � �� ; zrr l Liquid Capacity: 10r)C c- I_ Number of rings used: _ Tank manhole cover elevation: ���• Z$ Tank Inlet Elevation: 27--00 Tank Outlet Elevation: Number of feet from nearest Road: Front Side, Rear, O 4�S feet From nearest property line Front,0Side,QRear,0 3z feet Number of feet from: well & ' , building: _,2,6 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SF.R &RVF.RSF.. 9 DR PUMP CHAMBER Manufacturer: y 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 liner Front, 0 Side, 0 Rear,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed:Co, de ,:ft Trench: Width: 1E' Length: 6 ^ Number of Lines: S Area Built: 61 s_ „ Fill depth to top of pipe: V Z Number of feet from nearest property line: Front, O Side, O Rear,OPt Number of feet from well: '5 s Number of feet from building: t (Include distances on plot plan). r 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 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 job: License Number: 3/84:mj • SAFETY&BUILDINGS DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ON I LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVISING P.O.BOX 7969 MADISON,WI 53707 state Plan I.D.Number: M4 -R19Al 'CONVENTIONAL ❑ALTERNATIVE (IftePlanI. Town o j Hudz o n ❑Holding Tank ❑In-Ground Pressure ❑Mound Jacobs Landing NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam IViUeA Route 1, Box 282, Huclrson, W1 54016 � -16, 0o BENCH MARK(Permanent reference pmntl DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: JFSTRII.PT.ELEV.. Name of Plumber JMPIMPRSW No.: County: Sanitary Permit Number: Doug StAohbeen 5432 St. Ct oix 112739 i SEPTIC TANK/HOLDING TANK: MANUFACTURER'. LIQUID CAPACITY. TANK INLET ELEV.'. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER Qh PROVIDED. PROVIDED �tA s�e iuo0 91 , � l l -S3 ®YES ONO DYES ®NO BEDDING. VENT CIA I VENT MATL. HIGH WATER NUMBER OF ROAD PROPERTY WELL. BUILDING.1VENTTOFRESEI f.= ALARM FEET FROM 1 LIN:� AIR INLET DYES ©iNO + ❑YES YNO NEAREST DOSING CHAMBER: MANUFACTURER JBIEDDING LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO DYES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT 7EFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ❑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 IDISTR PIPE SPACING. COVER JIN1111 CIA &PITS LIOUIU BED/TRENCH TRENCHES. I M TERIAL' PIT DEPT DIMENSIONS /8 ` S GRAVEL DEPTH FILL DEPTH JDISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PROVE RTV WELL. BUILDING VENT TO FRESH BELOW PIPES ABU E COVER E(L�EV.INNLET E/L�EE�V.ENDG ^ �^ PIPE`SS FEET FROM LINE'.p� AIR INLET 611 'T "I t v�� I 1 ta`V C���1 V NEAREST V �� 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. ❑YES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WE 11 1:1 YES ❑NO DYES ONO JOEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL IS ODDED SEEDED MULCHED CENTER EDGES DYES ❑NO ❑YES ❑NO DYES [:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH-. LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL.&MARKIN(, ELEVATION AND ELEV.. ELEV.. DIA. ELEV.. PIPES DIA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED COVER DYES ❑NO DYES 1:1 NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING" FEET FROM LINE. DYES ❑NO ❑YES NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE Zoning Adm.%nizt tote DILHR SBD 6710(R.01/82) -- SANITARY PERMIT APPLICATION COUNTY f� Fs�ILHR In accord with ILHR 83.05,Wis.Adm.Code STATESSANITARYPERMIT# 11 ,9 -43 —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 NO PROPERTY OWNER PROPERTY LOCATION (Q, /4 a, S T , N, R E (o dT P OPERTy OWNER'S MAILING ADDRESS, 0T NUMBER BLOCK NUMBER S BDIVISION NAME PAOXv 2 Z — 14 19Js*14-y C.ITY,PTATE ZIP CODE PHONE NUMBER VITY EAREST ROAD,LAKE OR LA MARK O ❑ VILLAGE i• 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family �3 OR ❑ Public(Specify): 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. 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 Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X Seepage Bed b. ❑seepage Trench c. ❑ See age 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): 4 *,j G 1S S ?T' %, Feet X Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons 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 A 1 ❑ Lift Pump Tank/Siphon Chamber ❑ 1 ❑ 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: STFo k t a�CLj 06 � -�� /V to- i ,,L Plumber' Address(Street,City,State,Zip Code): Name of Designer: Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# h 5 . C k r i S�c "' 3 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: 4 u./t & htc,Is n,, — <10 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee Groundwater ate Iss 'ng Agent Signature(No Stamps) Approved ❑ Owner Given Initial S h11arge Fe//e11 Adverse Determination '1 201 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 i r 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 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 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 8'% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; 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 BtB� included the creation of surcharges (fees) for a number of regulated practices which WiscorSER'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re�sut'e is used in your building is returned to the groundwater through your soil absorption e 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. SBD-6398(R.03186) i i 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 Location of property -SO,) Sw 1/4, Section Township &4, J,50 2q Mailing address oet l If o, /`T"('S", i_�� _,'" V6 Its Address of site A 8 L ✓ 0 aw dC Subdivision name hx Lot number -# q® Previous owner of property a k jF0 0 Total size of parcel _, .D - Date parcel was created It�L� If,V, Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)?J_Yes No Volume rand Page Number;, A Zas 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. �- S.U5 : ; 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 County Regist it of Deeds, as Document No. Signature of Owner Signature of Co-Owner (If Applicable) '�- —4- 5�i 64te of ignature Date of Signature 170CUMENI NO. WARRANTY DEED THIS VAC[ RESERYEO /OR RECOROINO OArA STATE BAR OF WISCONSIN FORD[ 2-!M! , 435417 . �►�t REGI8TER'S L ICE �" s1. C=X oo.*- i,raiaia.M,,. tlansgn, a single woman f ed for Rena ........ .... ...... .. .. . . . . NAIL 99 ......._ ... .. .. .. .. ......... . ..... .. ............. .. .... 8:0o A M conveys and warrants to . Sam.-E. Miller...a..single man... ........... 0 ... ... ..... .. i`g11Nr d 09� _.... .. . ........................ _.......... . .......... ...... ... . .... .... . ... ..... .. .. ......... ... ............. .. ... .. . .. ............... .... RETURN TO .... ... ......... .. ... ........ . the following described real estate in ......St. Croix County, State of Wisconsin: TaxParcel No: .............................. West Half (W�) of the Southwest Quarter (SW�) 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 :n Vol. 6, Page 1747, Doc, No. 419479. That part of the West Half (W;l) of the Northwest Quarter (NWIy) 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. TRANSFEh� 0 EEE This . is not.......... homestead property. *kjt (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. Dated this .... ... .. _. .. ... day of . .PlArc ,/ ! 19.$$ .(SEAL) ( .l �gtxK �/f1►��L.i. �-V..(SEAL) . . ........ ..... ......... .......... ......... ......... . . ... • .Virginia.M...Hanson . . (SEAL) .(SEALI AOTRUNTICATION ACBNOWLXDGMZNT Signature(s) ............................................................ STATE OF WISCONSIN as. 1 r f T.\.�o.%k............County. authenticated this .......day of........................... 19...... Personally came before me this ..°�.. .......day of ........(.hpl.rc -................. 19.$$... the above named Virginia-M....Hanson................ • TITLE: MEMBER STATE BAR OF WISCONSIN _....................................... ..................... ...... (If not. .................. ..........:...................... authorised by 1 906.08. Wis. State.) to me known to he the perpon who executed the ...... ... foreggoin rumen( nn� ni�knowledge the same. THIS INSTRUMENT WAS DRAFTED BY t)1 $.A:..rturra . He ,-ood Cari S Marra ...... .. ..... ....,54016 . 'Qotn {� �y. (�. "' County, Wis. (Signatures may be authenticated or acknowledged. Both My pil U l��It�t iXe g.(If not, state expiration are not necessary.) date: •Nanm of aenons•litning In any capacity shnulet be l,pal or print+d Mdnw IhOr vlslamar•. WARRANTT DEED STATE BAR OF WISCONSIN wisran.in legal 111aM, I".. I,..- VMRM Ne a- vin %;.P.ke., tt'I•. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER "tom ROUTE/BOX NUMBER P � �jc�� ZqZ- FIRE NO. CITY/STATE /4" d SIO -1- w.T- ZIP , � 'o �(e PROPERTY LOCATION: S a ) 1/4 x_1/4, Section a , T �'1 N, R—A--62 Town of fgccOso� r , St. Croix County, Subdivision Lot No. )0 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. , SIGN , DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street w Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address T OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUS TRYY,NT INDUS , c DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS BOX 76 (H63.090) &Chapter 145.045) LOCATION: SECTION: TOWNS Atom, ONO.:BLK.NO.: �B��ON NA�- Sw '4�1/ 02 1 A-4N/Rf9I(o COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: S f i .� M ,`!/er ro l ,BJ-GO1 Q. v,� Gt1�s r SO<;L USE DATES OBSERVA IONS MADE INO.BEDRMS.: COMMERC AL DESCRIPTION: PROFILE DESCR PTIONS: PERCOLATION TESTS: Residence „//� New ❑Replace I 7 � d� p� �`� Al AC PX CI- O 7i RATING:S=Site suitable for system U=Site unsuitable for system 6— ST Barret�g/yr� / CONVENTIONAL: MOUND: MM ND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) ®$ ❑U ©$ ❑U $ ❑U ❑$ ©U ❑$ ©U L° If Percolation Tests are NOT required DESIGN RATE: [Floodplain,f an f A y portion is the tested area is v the under s.H63.09(5)(b),indicate: /(/ indicate Floodplain elevation: PR FI E DESCRIPTIONS BORING TOTALO ELEVATION DEPTH TO GROUNDWATER-4+0Ht15• CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH+ OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 1 7r� r B/t Q �s aZ O.t d g /S A/ B/t s B- Z /• �I 9.�� NDA�I� 7 r�i �6 BnB.r/s, • y �n eg 3.3,6 c s B- 3 20 ' ,Lf /I,jo,u v �y & �S s/, r 3 dH�- /s, y y Bh p,es, B- Y 9. 0' !9•` ' ILIO x e- 7 v .3 IfA co j- /S 3. '?%�' DI� / /r ► r B/I Y' S�� r (� Cob M /S, 2.2 IV�1 s/ r GS C- B- PERCOLATION TESTS TEST DEPTH' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INGI IES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P- / .lr o 2 4 C e, 3 P- Z *0 2 6 L 3 P- 3 2.0" 0 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 l�. b' sc,��� _ yo• ,�e _ I a _ \1 I i _�- N 3 O iei _i4ir........ ° j / Q iA we 0 ,mm C 1 E 3 __I . � .... r _. ___ , wie [ t _ I I 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): �0 1 TESTS WERE COMPLETED ON: l/Peo ,f (��h��To �erlGv S--02^ o rrx ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): *er AjsdAl, 2 CST TUBE: + c DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. D I LH R-SB D-6395 (R.02/82) —OVER — N INSTRUCTIONS FOR COMPLETING FORM 115 - SBO - 6395 To be a complete and accurate soil test,your report must include: s 1. Complete legal description; 2. The use section,must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; S. 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; B. 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'; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9, 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 Soil 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 Grourtdwa"per Cs Coarse Sand Perc -- Percolation Rate med s - Medium Sand W - Werll is Fine Sand Bldg - Building [s - Loamy Sand > - Greater Than sl - Sandy Loam < Less Than �l - Loarn Bri -- Brown s i I - Sill Loarn BI Black si - Sill Gy - Gray cl -- Clay Loarn Y - Yellow scl - Sandy Clay Loam R - Red sicl - Srl y Clay Loam mot - Mottles � t Sri Sandy Clay w/ with sic - Silty Clay fff - few, fine, faint C ..... Clay cc -- cornmon, coarse pi ._ Peat min - Many, medium sri Muck d - distinct p - prominent #�V - High vvater level, Six general soil textures ;. surface water for ligl lid waste disposal >ve BM - Bench Mark AlFIP" - Vertical Reference Point" TO THE OWNER: This soil test re:poo is the first step in securing a sarlit€ary permit. The county or the Department may request verification of this s>a;l test in ttae field prior io €)errnit issuance. A {ornplete set of plays for the private se,,aade systeui and a permit applicaaion must he suh,asitted to the appropriate local awhoiiiy in order to wEatfa ,r a p,,-wnnit. The sanitary ,wrfTJl mr.is?: be obtained and posted piior'to the star€ of any Construction. J I • A ' Tl ^ P � p LA Ob C -Ilk-Ilk ° N 014 Vb P IA s A \' Y t t 4 M1 l rr u � i r u � � p N o P f � o I f O oft Ap f _ - I 11 r i ' 111 . ` J1 � 1 1� �1• t--. ij ab x N � N Q� • • 6� i � p � H • .P (( I P fix fir-+ 9 ` P o 1 -d � Or �D p P f Fi t o;, ST W