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HomeMy WebLinkAbout020-1190-40-000 O 69 c c d 4 0 � m o m CL I N o O O N O C d � I y = 0 I L O q C C O•y N O N O 4) aNi aEi C v Z N C 7 tC Y y LL C Q O. O V C_ -v E y Q w d' y M Z 3 E !' 00 Z a� m CN H z d m o c o z v v Z N = c ca _ a (D c C v O L .0 c O o c Z Co D o v� Z C @ C y 01 c E O `N C m N a� L a 1 CO rG rC d E L LO 3 3 = o a in Z N � � a a a H 4i d c N J rn U rn 2 � � v I O v o 0( D N = E m °' :? co 3 a 2 H y 0 N d E r In O E co o 0) CD N l o y O O N N N r O C N t O c O V •IV �' O N 2 .- O Z F- V = E E a I 3 �t a ` a �, • am .2 d 'N +� E E E ° Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP H ct S SEC. 2 T -x` N-R PF ro ADDRESS 12.* �Jchl Z g L ST. CROIX COUNTY, WISCONSIN SUBDIVISION ,lctab S gyp,.1 rf LOT # Z� LOT SIZE Z PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Sy-5-T-f61,E/ t0 3.5 .111 Yz✓' �a 3 („e/AFL o7 �b v C T k 1 fi � ' I A-5 � I W a INDICATE NORTI ARROW i BENCHMARK: Describe the vertical reference point used i� /o'r J11' IOU, i Elevation of vertical reference point: A*3 . - : Proposed slope at site: /j SEPTIC TANK: Manufacturer: Liquid Capacity: / z3� Number of rings used: _ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front ,O Side, Rear, O / 7,5 feet From nearest property line Front,OSide,ORear,l J feet Number of feet from: well !' building: ,39 ��oM sW Cot hed (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, 0Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: C,*,oj 'o..a/ Trench: — Width:f Length: Z Number of Lines: _ Area Built:9 3e.' Fill depth to top of pipe: y Z Number of feet from nearest property line: Front, O Side, 0 /P%Rear, lft . Number of feet from well: /3 S' Number of feet from building: �P / (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, O Ft. 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: 'i 3/84:mj is DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 NW'-,, SW%, 3707 9N—R19W NkONVENTIONAL El ALTERNATIVE State Plan I.D.Number: Town of Hudson El Holding Tank ❑In-Ground Pressure El Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE _ Sam Miller Route 1, Box 282, Hudson, WI 54016 — (2— ��' BENCH MARK(Permanent reference paint)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber. MP/MPRSW No.: County Sanitary Permit Number: ►►2VS3 Doug Strohbeen i5432 St. Croix 112661 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. OYES FIND OYES ONO BEDDING. VENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. JVENTTOFRESH ALARM FEET FRO LINE AIR INLET DYES ONO OYES ONO N DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVI DED. PROVIDED: DYES ❑NO ❑YES ONO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) 1:1 YES ONO 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 JINSIDI DIA st PliS LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UIS7R.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. PIPES FEET FROM LINE AIR INLET NEAREST--a- 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. DYES 1:1 NO SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =PSOI1 SODDED SEEDED IMULCHED CENTER EDGES. ❑YES ❑NO ❑YES ❑NO : YES 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 MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATEHIAE.8,MARKING ELEV.. ELEV. DIA.. ELEV.. PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PVEARTICAL LIFT CORRESPONDS TO APPROVED El YES El NO El YES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY 7=ING. FEET FROM LINE 1 �p ❑YES NO ❑YES ❑NO NEAREST .(kin Sketch System on p Retain in county file for audit. Reverse Side. J Y. v [SIGNATURE TITLE. Zoning Administrator DILHR SBD 6710(R.01/82) i SANITARY PERMIT APPLICATION COIN, =&.HR In accord with ILHR 83.05,Wis.Adm. Code • CPO/ X STATE SANITARY PERMIT# —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 [9 NO PROPERTY OWNER PROPERTY LOCATION C ��'/a k1'/a, SZI T217, N, R E(O PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CI Y,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LAfiDMARK / Z VILLAGE i� 11. 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.� 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.V Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. E:1 Vault Privy e. El Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X 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): 3 61.5-- 3.,5'' Feet Private ❑Joint El Public VI. TANK CAPACITY Site in gallons Total ##of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank 1W ❑ 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): Plu ber's Signature:(IN Stamps) MP/MPRSW No.✓ Business Phone Number: tA ry S{�aH — 3 2—.3.3 Plumber Address(Street,City,ktate,Zip Code): Name of Designer: q_c -�'c-kowo o t V a k14 SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST#/ CST's ADDRESS(Street,City,State,Zip Cod Phone Number: Q 4-14,1 A d®.- /, s o wZ O / ::;,L OV I COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial urcharcge Fee ,Q 7 Adverse Determination `�� M36'6c) X. COMMENTS/REASONS FOR DISAPPROVAL: 7� lay. 042PT'oJ4ck 4 _t ,ok`c-3 C . SBD-6398(formerly Plb-67)(R.03186) 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 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; 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 [— included the creation of surcharges (fees) for a number of regulated practices which Wisco S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried [e'BStit°B ° 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) 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 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 SdroW /J1,'11c✓- Location of property 4W 1/4 1/4, Section T a N-R/l' W Township f' cZk !�1 Mailing address Address of site 14 �'.t. . Subdivision name ,��.co S s ��k�•�. a /S d '� Lot numberyM. Previous owner of property �f;rt h i�, �•�Al S®/' Total size of parcel -.Z. O / Z 11,e cty S Date parcel was created Are all corners and lot lines identifiable? �� Yes No Is this property being developed for resale (spec house)? es No Volume .. I and Page Number 41IC7 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 P Y 9 P 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. 4/3 <-411Z ; and that I (We) presently own the proposed site for the sewage disposa 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 ounty Registe of Deeds, as Document No. �f3 4W 7 ) . Sign ure of Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature ll l)OGUMENI NO. TNIa a►ACa acscavcD FOR accoaol,le Data !? i WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-111182' , ?� 435417 �:. nwc REGISTER'S OFFICE � see cRax co., vrn fted for Record Vi,rSini,a.M.. Reason, a single woman... . ........ ........... . . . . ........ .............. ........ ... _ ..... ... . ... .. ............._........... . .. MAR Is 10 . ... .. .. ... ......... . ....._.. .............I .. .... if 8:00 AM .. .. ...... . ..g. . . _..................... e conveys and warrants to . Sam-E.. Miller a..ain le man... ........... . 0 &,,� . ...... . . ... ...... ... ......... ..... r�MSr ftl O��i _ ........ . .. . . .... ................ ... . ... ........ .. . ........... .............. �. .... ....................... . .......... ....... .... . ...I ...._. .... ..... ... ... .. ... ......... ................. .. ........ . ... .. ... w[TURN TO ... ..... . .... ... ... ... ...... ... ..... ... .. .................. .............. ........ . the following described real estate in ......St. Croix ,.•_.County, State of Wisconsin: TaxParcel No:................ .......... West Half (W�) of the Southwest Quarter (SWIx) 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, Doc, No. 419479. That part of the West Half (01) of the Northwest Quarter (NWk) 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. �SFEh� 0 EEE This .. ..is .not.......... homestead property. *kk (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. Qr Dated this ... ...... ... .. .... day of . . 0-.0 119-88 _. . ..... ...........I ... .......(SEAL) �/.l �gt.�1cK•R�i//e�tC/Ztli� V..ISEAL) . ........................ ...................................... • .Virginia.M...Manson..... . .. . .. ... . ........... .... ........ . .. ...... . . _.. .(SEAL) _ . _(SEAL) AOTHUNTICATION ACENOWLSDOMBNT Signature(a) ............................................................ STATE OF WISCONSIN ....................................... r as. \-.... ............County. authenticated this ........day of........................... 19...... Personally came before me this ... ... .......day of ........n'1p1.�c --................. 19.88... the above named ................................................................................ Vir iris M. arson TITLE: MEMBER STATE BAR OF WISCONSIN ................................................................................ (If not. ............................:............................... ......... .............................................. ....... ............... authorized by 4 706.08. Wis. Stats.) to me known to be the rerpon ............ who executed the foregoin trument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED 9Y ...... ......... .... . . '...�. ... ...... ............... (14�4�4..�:..MuFF.RY.a..Neywoods,•Cari..b.,MurraY.,•. '• P..O,...BRx..229,..HttdNQAa..�II..... 4016. 1•otar. nt♦ltc y (i. "'.. County, Wis. (Signatures may be authenticated or acknowledged. Both My Co mi ��IC�/>�I�A41ent.(If not, state expiration are not necessary.) date: . •T �� ...... . •ftron of Persons sisnlas to any capacity should be typed or printed 1.4ow tbOr.iannture.. WARRANTT DEED STATE BAR OF WISCONSIN wisronsin I'mal Itlank 1•., In.. FORM No !— 19sP lWw..•kw, Wf•. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER lyl // AZ ROUTE/BOX NUMBER_ et*z &X4f 2- FIRE NO. —� CITY/STATE 64"�V 4 0/L ZIP =E;901 PROPERTY LOCATION: ,�/w 1/4 5k,/ 1/4, Section Z , T-2, R/� Town of #ee_ S01t KW"- , St. Croix County, Subdivision �J_4eDL S lai.S r R5 , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents NAY 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 6-7- 8 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 DEPARTMENT OF' REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON,WI 53707 (H63.090)&Chapter 145.045) LOCA�TJION:S SECTION/: Q TOWNSHIP/ OT NO.:BLK.NO.: UBDIyISION NAM �+ 1/wV/ aZ 1 /L2/ N/R/9'1?(or LG4 SIOA.* 2, .� �9C+�+s IS It COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBS15IRVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER ATION TESTS: Residence New ❑Replace I Sv.'/ M-41 h C Z RATING:S=Site suitable fors stem U=Site unsuitable for stem �S LCN d f -OAK O Y Y -5-91 � r IC1217is ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) ❑U ®S ❑U ®S ❑U ❑S ®.0 ❑S ®U e� If Percolation Tests are NOT required DESIGN RATE: 9 If any portion of the tested area is in the under s.H63.09(5)(b),indicate: lFloodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH4#C ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) .� •S 40!1 ' `7 Bn 1 • `!� ,Bit �-/� / G rB" S B- / 7,s v7• a,,Ie- 7 7,r s B-.2 �S' c2 .,? a SB I S D S B- PERCOLATION TESTS TEST DEPTHO WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER +NEI+t@S AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD2 PERIO PER PERINCH P- O Z {o L P- I. Y.3' A10 2- 6 6 G --? P- .o' jV0 2 6 6 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 /©3• �' V _._... zk 3 a ID P� ? P► i ice' P _ A • � - q ',T •1� 11 ff �a e I _- t i t �#'�J ��, L L_ C 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 ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CS TUBE: r � DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — e D INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5395 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 a new or replacement system; S. Complete the suitability rating boxes. A SITE =S 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.; 1, MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A separate sheet may be used if desired- 8, 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 not apply, place N.A. in the appropriate box; 11. 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 1NITH THE LOCAL AUTHORITY WITHIN 36DAYS OF COMPLETION, ABBR1lIATIONS FOR CERTIFIED SOIL TESTERS w , , Scan Separates Ind..Textures Qther Symbols A st — Stolle (over 10") BR — Bedrock cob Gobble (3- 10") SS - Sandstone gr - Gravel (under 3") LS Ln;estone �s — Sand HGW — High Grousrdwater cs - Coarse Sand Perc - Percolation Rate coed s — Medium Sand W - Well fs -- Fine Sand Bldg — BUilding Is — Loamy Sand ) — Greater Than �sl -- Sandy Loam < -- Less Than '-I — Loarn Bra — Brown �sil Silt Loarn BI - Black $i Silt Gy -- Gray �cl — Clay Loam Y Yellrays scl — Sanr.y May Loam R — Red sicl — Silty Clay Loarn mot — Mottles SC Sandy Clay w/ — will) sic — Silty Clay fff - few, fine,faint c : Clay rc -- coran'ron, coax of -- Peat FTrIII — Many, I'TWdium rn — Muck d — distinct p — prominent HWL — High water level; Six general soil textures surface water for liquid waste disposal BM — Bench Mark VRP - Vertical Reference Point . k TO THE OWNER: This soil teSt report is the first step in seerrrirru a sanitary permit.The county or the Department may request v€r"`ication of this soil test in fire field pr crr' to f,rrrnit issurrnce� A comple�tre set cJ planes for thr-t private se v;rg; system and a permit auq)lication must he suhlnitted to the approp;-ial ? local auihorit" in order to obli;'in a pet"mit. -Fire sanitary I crn;rt rnusrt be ra,imf eki and pr..too lei ror to Lhe Shit"Of any t:C r1 tEUCt3i}€1. AVY� Ul ttq-rr 2KTS J K g IK, -,F Kos;i e Sc 1t-- /Vii_ lev t S W �oQ�a ft C Z�XZw' Di i vc w4 y 7 / l A l ft-(AaT �j I scKtl, lot 'it�a.. II w,• LA ( a 1 �1 Al 1 4 vJ t ` b t F7 P c S � t tr f P 0 Jt LAP A • P f . �. - ,•: ••rte •� �. . . W W `'t,`• ^'