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Form - S T C - 104
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AS BUILT SANITARY SYSTEM REPORT
OWNER /y �� Q✓ TOWNSHIPS t�� SEC. T �N-R ' W
ADDRESS ST. CROIX COUNTY, WISCONSIN
�aar� ZB'Z
SUBDIVISION ���� b s /�k�; LOT / LOT SIZE z . zc¢�✓
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used a+ /VcyC��KQ,'
Elevation of vertical reference point: 00-6 Proposed slope at site: 7 SclJ
SEPTIC TANK: Manufacturer: Liquid Capacity: .2--Z-6
qq /
Number of rings used: Tank manhole cover elevation: �ri IL?
Tank Inlet Elevation: ,17/ Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side 0 Rear, PIS feet
From nearest property line Front,0 Side,0 Rear,0 3 feet
Number of feet from: well building:-4 tNocorAol 'd- ,ZD r
• -4, .re.tom kJ � < p ul
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
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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: -
Width: Length: 3 6 Number of Lines:__ Area Built: 77'-
Fill depth to top of pipe: -�4 z
Number of feet from nearest property line: Front, O Side, Rear,
O ht .3 z
Number of feet from well: /D 7 ,
Number of feet from building: 'S -7
(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
f
- 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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector• f �1
j�_g
Dated: Plumber on job:
License Number:
3/84:mj
'DEPART'MENT OF IN USTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIV ON
ISI BUREAU OF PLUMBING
P.O.BOX 7969
MADISON,WI 53707
N(U%, SW!, S21,T29N-R19(U DUCONVENTIONAL ❑ALTERNATIVE (If signed)D Number
(If assigned)
Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound
Lot 11 Jacobs Landing
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
,
Sam M.rUetc I Route 1, Box 282, Hu,dtson, 61154016 ?- a 9- g� a,3C)
BE MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: I,;*,,,REF.PT.ELEV..
Name of P mbe MP/MPRSW No.: County: Sanitary Permit Number:
Doff .St.ohbeen 5432 St. Ct oix 112709
SEPTIC TANK/HOLDING TANK:
MANUFACTU ER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING ELABEL LOCKING COVER
PROVID EPROVIDED.�SYE ❑YES O
BEDDIN VENT DIA. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WUILDING.1VENTTO RESH
) M FEET FROM 1LINE i AIRINLE❑YES ❑NO 1 YES NO NEAREST
DOSING CHAMBER:
MANUFACTURER JBIEDDING LIOUID CAPAC Y 1PUMPIMODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL I LOCKING COVER
PROVIDED: PROVIDED.
DYES ❑NO ❑YES ONO I DYES NO
GALLONS PER CYCLE: uMP AND LS OPERATIONAL NUMBER OF PROPERTY WELL 113 UILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑ ES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check thesoi moi re atthed pthofplowing LENGTH IDIAMI,TER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a lire,construction shall cease until FORCE
the soil is dry enough h to continue.)
MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO.OF DISTR.PIPE SPACING COVER INSIDE DIA sPITS LIQUID
BED/TRENCH � TRENCHE CD f MATER PIT / DEPT/
DIMENSIONS
GRAVEL DEPTH FILL DEPTH I 1111-ITR PIPE DISTR PIPE IDISTR.PIPE MATERIAL. NO OISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO f RES
DIV BELOW PIPES. A VE COVERI ELEV INLET ELEV.END'. PIPES LINE. lO , AIR INLET
101" Y1i I D A ����� NEAREST-- 3�
MOUND SYSTEM: V - _
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 ❑NO
SOIL COVER ITEXTURE JPIRMANINT MARKERS OBSERVATION WE 11
❑YES ❑NO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SD IMICHIED U ',
CENTER. EDGES.
DYES El ❑YES ❑NO DYES ❑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 NO DISTH DISTR PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.' ELEV.. DIA.. ELEV.. PIPES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING. GRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
DYES 0 N ❑YES 0 N
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE.
DYES 0 N
-]YES NO NEAREST
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Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE
Zoning Admi Z t ato&
DILHR SBD 6710(R.01/82) .4L d
=Z04 SANITARY PERMIT APPLICATION COUNTY
LHM In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY P�MIT
—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 OWNE PROPERTY LOCATION
4 � a, S , T , N, R E (O
PROPERTY WNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY,ST TE tCiy ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR NDMARK
1 �.'G VILLAGE: ,SG�N 0��✓ v%
TOWN OFO II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family ,� OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a/VNew 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.X0 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. Seepage Bed b. ❑Seepage Trench c. ❑ seeDacie Pit
2. PEFrCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ��jj
G_ Z" <0 4 ° Z Feet , -Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total ##of Prefab. Fiber- Exper.
INFORMATION New xis Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed L/ Ej __H Septic Tank or Holding Tank W L'(S¢
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) MP/MPRSW No.: Business Phone Number:
c,. Str-o k ti S�c%_ Al f,— S+I (Z51 7 23
Plumber' Address(Street,City,State,Zip Code): Name of Designer:
k�� � S S�io � �cs
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST##
ST's ADDRESS(Street,City,F4ate,Zip C e) -/ Phone Number:
(,w I,/e/ UL— 'O � �/C7li v�S�o
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issui Agent Signature(No Stamps)
I��P urcharge Fee
L�51Approved ❑ Owner Given Initial �. /
Adverse Determination / l
X. COMMENTS/REASONS FOR DISAPPROVAL:
Ian
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
I
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;
ll. 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;
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 816 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 tB[
included the creation of surcharges (fees) for a number of regulated practices which Wisco
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Te3SIC$
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.
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-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
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^ 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 -'S,4 ,n /�l.' //,C,"
Location olf� property w 1/4 -SW 1/4, Section , T--=;�9' N-R���
Township /TUC/ Sov�
Mailing/ address a'< Z 2'-
{ Address of site #a1-Ac'r 111,4t.41 'Sol
Subdivision name G S 4-w % �5� Ado
Lot number 't//
Previous owner of property bl"i Illr ;A- 144ti6c
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? ,- Yes No
Volume b and Page Number `I ; Z 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
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. _� .5:- ` /? ; 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. Y 2 .551/ ? ) .
JL
�� Yl
Signature of Owner Signature of Co-Owner (If Applicable)
-7- / )-- - S '�
Date of Signature Date of Signature
DOCUMENT NO. WARRANTY DEED TN1s •rACC Rc•gevgo row accoaols.o onrA t
i STATE BAR OF WISCONSIN FORM 8-00
435417 �y REGISTER'S OFFICE
Vi,rsini,a.M.. Manson, a single woman. ... ........ ........... .
. .. ..... .............. ...... .. .. ..... ... .. ............. ......
TAR Is
. ....... ...... . ......I............. .. .. ... ......... . ..... .. .............. .. .... of 8:00 A iM
_... . .._. ...... . ..... . . ......................
conveys and warrants to _ Sam-E.. Miller...a..aingle man... ........... 4
...... .. . ... ...... ..... .. . ....I... ..... .......I ... ......... ..... (1R01Mp sl OMi
... .1.1... ........ . .. . . .... ...........I.... ............................
. .. ......... .... ............ ........... . .......... ......._... . .... .... .. .... .....
.. .... .. ... ......... ................. .. ........ . ......... ... .. . . .... RETURN TO .. _
the following described real estate in ......St. Croix „_-.,••County,
State of Wisconsin:
TasPared No:..............................
West Half (W]�) of the Southwest Quarter (SWIx) of Section
Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19)
a 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, Doc, No. 419479.
That part of the West Half (Wil) of the Northwest Quarter (NWT) 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.
SM 0
i
EEE
This .. _is .not.......... homestead property.
0dt (is not)
Exception to warranties: easements of record and protective covenants and restrictions
of record, if any.
}�
bated this . •� %1r) S .... day of . .9 r ' !R r.t L, . 19-88 ..
.. ..... . ...... ........... ... .......(SEAL) "-V..(SEAL)
. ........................ ...................................... • .Virginia.M...Hanson..... ......
.. . ......................... . . ........ . .(SEAL) .(SEAL!
AUTHENTICATION ACENOWLBDGKZNT
3i�llatare(a) ............................................................ STATE OF WISCONSIN
................................................................................
r ss.
�. u.�k.............County.
y .............. 19...... Personally came before me this ..°�.�.......day of
authenticated this ........da of............. /
................................................................................
.....n p1.!ai-................. 19.88... the above named
Virginia-M....Hanson............................................
•
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not.............................:...............................
authorized by 1706.06. Wis. State.)
to me known to be the rerpon ............ who executed the
foregoin trument and i.Anowledge the same.
THIS INSTRUMENT WAS DRAFTED BY Y�
...... ........ .. . . . .; �. ... ......_...............
4#a.!A,.. 4!11'RY....Neywoods. Cari.. _ Murray ,�Aw ''
• Ci v�•�
P..Q....ROX..229a..t1AS(gSlns..�1I,•,. 4016 ...... ........ Notary u1+1(c "�•y: (�•."`. County, Wis.
(Signatures may be authenticated or acknowledged. Both My Co mi �iflft W6 ent.(If not state expiration
are not necessary.) •,r
y date: ...?�{. .....,... ..... ............
•Nanwa of Do as signing in any capacity should be type•l or print.d holow th.dr Plannuros.
WAJUtANTT DSED STATB BAR OF WISCONSIN wisronsin 1..7&1 11lnnk 1'... in.•
"RM No S— I7nE �1.,�..•1e. WM.
i
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER )0-
ROUTE/BOX NUMBER FIRE NO.
CITY/STATE ZIP
PROPERTY LOCATION: N4) 1/4 1/4, Section T_rN, R W
Town of UC' 's0L%_ cs* , St. Croix County,
Subdivision Za- C y V' fr , Lot No. N _.
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
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGN 6 )17 it
DATE - r 2 �-
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016 ° w
(715) 386-4680
Sign, Date, and Return to above address
i
DEPARI'MENT OF REPORT ON SOIL BORINGS AND SAFETY_& BUILDINGS
- INDUSTRY DIVISION
LABOR AND PERCOLATION TESTS (115) P.O.MADISON WI 7969
HUMAN RELATIONS,
(H63.09(1)&Chapter 145.045)
LOCATION: TOWNSHIP O/T NO BLK.NO TaSIO
Tv� N/RI /(o ti sa�/wS�X aZ l /
r (�.•d.;l,�- srt
COUNTY: OWNER'S/BUYER'S NAME: MAI LING ADDRESS:
4 Gb,` S .tic �-t:�/��- -tao/� J . I)
USE _ DATES OBSER ATIONS MADE
FN NO,B�DRMS. COIVIIN�Fi�:iAL'D S�RIf''T`ISN': �O�TL1=�[5E$�;1�TFfT1aT3�: PET�O�A-Y'IZSN� S
Residence / ,New ❑Replace — Z- 1 y' P
RATING:S-Site suitable for system U_=Site unsuitable for system (� �-� .. h1 e 1,6 0_
ON ENT NAL: MOUND: IN-GROUIVUPFt URETEIS -IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) .,
r o�[gSDU �. WS ❑U U ❑S .®U _ oA4 �� �8�� �ZY 'xY 1
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: /iF>i Floodplain,indicate Floodplain elevation: -�C— -
PR FI E DESCRIPTIONS
e
BORING TOTAL-4 DEPTH T R UNDWATER CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTFIMI, ELEVATION OBSERVED HES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
14 .,e L( A IS . SB CS L. CS
7.
B- .3 7.J /v3.-y Or .381S6 7 2- An 94- C S.
B- `f 7.3' Ajaoyl A.&At e- .S " s .Ir A. et s
B-S" 7.S_ a S ' o f c e_ 2 >. s' , 5`6 1 S • 3 s C
B-
PERCOLATION TESTS
IESI QEPTH$ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE M NUTES
NUMBER 4#Q"6fi AFTER SWELLING INTERVAL-MIN. PERIOD I P RIOD2 PERIOD 3 PER INCH
P_ Y.3' A1.0 Z 6 6 3
P_ L .7.
P- 162 Ca <
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 / o /• ffe4 le- e- 6
r-
•r,f>rt
_. �1C
7 32' .320,
k a.lP ._o _ _. 4d
A 4e 01
o
to �^d .
B .
-
FA.
w
I„_ J
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). [ TESTS WERE COMPLETED N:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional);
.S�o S-7 -
CS ATU E: `
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DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) OVER -
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