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HomeMy WebLinkAbout020-1190-60-000 \ ° ( \ \ \ & o Nt 2 § t* _ {0 k V;2 � � j { 0 7 \} . % 2k � 4) 75 ) Z \/ cc E \ k § � � \ � b � o & / § I ) q co k z 2 \ « « § 0 $ 7 7 E ' e n � \ � } ƒ ƒ § ) § 3 z ca \ z k % 2 0 ~ R (D a k IL ) =8 U) k k � E « t � $ 2 a 2 a ' j \ ) } } o z = ( § ) § \ t = ° Q � 2 < ■ 2 § G G o k f o \ \ @ 3 9 B § \ e � m I G % a § § 2 z ) 2 ® ( ( k q k I ) 2 o r k a 0 -� o _ ' & c z _ e ■ m zk . C & § k /a 2 0 3 0 * r e Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 54Ay �s//�✓ TOWNSHIP We,is�, n SEC. T N-R 7 ADDRESS 4 ,94*l ZOX ?'g 2, ST. CROIX COUNTY, WISCONSIN Lye SUBDIVISION J6�o6s /t�y��kg LOT /� LOT SIZE Z• OD ,lrl�r 5 PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM j syS��� � l, = 9�•q r y 5'6• \ 3 z - �° 31 0 h�, r � r P �G r T a N INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: (�.9 Proposed slope at site: le-/z 5 u/ SEPTIC TANK: Manufacturer: `(Ju;Cdr Liquid Capacity: �oon GZ� J Number of rings used: O Tank manhole cover elevation: l e9 Tank Inlet Elevation: C Tank Outlet Elevation: , Number of feet from nearest Road: Front,wSide o Rear, O /j�' feet From nearest property line Front 10 Side,©Rear,O feet Number of feet from: well %r, , building: hQ� (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE f r � 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,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 4e'�6n ✓Q ti'�,'B.Lci / Trench: Width: Pr" Length: 3L Number of Lines: Area Built:lo 9�� Fill depth to top of pipe: z Number of feet from nearest property line: Front, O Side, Rear,0 Ft .� Number of feet from well: l0 S Number of feet from building: S (Include distances on plot plan). SEEPAGE PIT Size: '0 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). I HOLDING TANK Manufacturer: A/A 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: cL) .... L License Number: 4- _. 3/84:mj • • SAFETY&BUILDINGS �DEPA•RTMENTOF INDUSTRY, INSPECTION REPORT FOR DIVISION LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI 53707 NW1,4,SW4jS21,T29N—R19W KXCONVENTIONAL El ALTERNATIVE State Plan l.D.Number. (If assigned) Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 14 Jacobs Landing NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Miller Route 1 Box 282 Hudson WI 54016 7'�1, -�g r/` BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber MP/MPRSW No County: Samtary Perron Number: Doug Strohbeen 5432 St. aoix 112652 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. PROVIDED PROVIDED LOCKING OVIDED COVER DYES ONO OYES ONO BEDDING. VEN7 DIA.. VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING.(VENT TO FRESH ALARM FEET FROM LINE. AIR INLET -]YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ❑NO ❑YES ONO DYES ❑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) OYES [11 NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH JUIAMETEH 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 SPITS LIOUIU BED/TRENCH TRENCHES. MATERIAL! PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DE DISTR.PIP DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PROPER TV WELL BUILDING VENT 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. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS UBSEHVATION WELLS 1:1 YES ❑N OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED F'"',E]YES MULCHED CENTER EOGES DYES ONO ONO 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 IN O DISTR JOISTR PIPE DISTRIBUTION PIPE MATERIAL&MAHKING ELEV.. ELEV.. CIA.. ELEV.. PIPES CIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS CAL LIFT CORRESPONDS TO APPROVED DYES ONO El YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF��P46PERTY LINE o WELL: BUILDING. FEET FROM [:]YES El NO DYES El NO NEAREST � ,vy Sketch System on L Retain in county file for audit. Reverse Side. SIGNATURE. TITLE Zoning Administrator DILHR SBD 6710 IR.01/82) I SANITARY PERMIT APPLICATION C�OU�NT"JY'" LEM: STATE SANITARY PERMIT# LHR In accord with ILHR 83.05,Wis.Adm.Code U� —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D. UMBER 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 MNO PROPERTY OWNER PROPERTY LOCATION /4,5 V14, S T 29, N, R E (o PROPERTY OWN R'S MAILING AESP� LOT NUMBER IBLOCKNOMBER SUBDIVISIO NAME Al CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST FICA J,LAKE O R 1-0413MARK L O S D a ,(� ❑ VILLAGE: v All 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. X 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. �9 Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. R seepage Bed b. ❑See a e 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): eo lfs_� G _1/e Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in ga ons Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank d �dr 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): PI mber's Signature:(No St mps) MP/MPRSW No.: Business Phone Number: _Dl, .Stra 1.,b C.e-9.1 Plumb 's Address(Street,Cit ,State,Zip Code): Name of Designer: a4-0 n E�J �i c � o�� f �.. ro(n. �115 al- VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## 16-11 4 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee Groundwater Date Is s g Agent Signature(No Stamps) �Qpproved F-1 Owner Given Initial 1 S rcharge Fee Adverse Determination 2�'c X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. 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; 11. 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 $18T included the creation of surcharges (fees) for a number of regulated practices which Wisco ik- can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Teo S41TQ 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. c 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 / Location of Property S 1?-111 14, Section Township AZ ),e Nailing Address /# Address of Site e� - S oj;7F Subdivision Name Lot Number Previous Owner of Property t'a-r Total Site of Parcel Ae aw g Date Parcel was Created - ::'. — :?-7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume � and Page Number 2-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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION i (We) ce ti.6y that a t 6tatements on this 60&m are thue to the beat o6 my (owc) knowledge; that 1 (we) am (are) the owner(b) o6 the pupenty dens cA i.bed in th i.6 in6onmation 6o4m, by vi tue o6 a waAAanty deed neconded in the 066ice o6 the County Regi6ten o6 Ueeda ass Document No. 4(3-:7- e//7 ; and that I (We) puAently own the pnopo6ed Aite bon the 6ewage d.id o6 dy6 em (oh. I (we) have obtained an eazement, to stun with the above debcAi.bed pnopehty, bon the condtnucti.on 06 6atd 6y6tem, and the same hae been duty neconded in the 066ice o6 the County Reg,t,6* Deed6, ad Document No. 1' 4// 7 ) . Ct SIGNATURES OP OWNER SIGNATURE OF CO-OWNER (IF AZ DATE SIGNED DATE SIGNED N$IN x1t 1 , sll�'tlNpi " V } is a k ....... . . ...•... . 8600 p"It -aad warrants to Aws,.Z• Mincia A aingle ... ti ^s _ # , ... .. .... ss� s " .............. .y ...-. Oba,followias daeribed red astM#.In St. Groiz County. state at Wisoo"ia: t r Tax rim"*a,. a - t Half (W;i) of the Southwest Quarter (S*) of,Section ' r y-on* (21), --.Township twenty-nine (29) North, Range Nineteen (19) . � 444e St: Croix County, Wisconsin except that part South of the public ` 1400ay-and except Lots 5, 6, 7, and 8 of Certified Survey Map in Vol. '6,' � � Doco No. 419479. 1 That .part- of the West ftif' (W1) of the Northwest Quarter (N*) of Section x 'Twenty-one (21). Townstfip;.Twenty-nine (29) North, Range Nineteen (19) We11t, 8t. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. C " NO# " i EEE ` a Rg +•'' .. x TFt y ' This .. ...ii..AOL......-... homestead property. i # (is not `v r 4 Exception to warranties: easements of record and n' protective covenants and restsiriir. of record, if any. x Dated this .'.. . .... ... .. . . day of i' ' rt: L' U._ ..... ... .......... ............ .(SEAL) ,`rG• ty6G4t-IMP. .................. . --• . ---- . .Virginia.M...Hanson..... :-.... ' .. ..... ..... ... ........ .... ....... (SEAL) S k ....... .. . .... .. ... ... ... _ � AUTRUNTICATTON - # AR: NOWLSDtilt>tiiliiT Sisaatars(s) ................................................... STATE OF WISCONSIN ..•..............•----------.......•..••............_........................ ' a& ........County. , 1 authaatieatad this .......day of........ 19 Penonaliy*me before me this .•y'X.. .•.•.............•.............. .! ,y .............. 19. .. Yu � " ion ` 13. ......................................... 4.M "; .. gYrn' MEMBER STATE BAR OF WISCONSIN r q� t t Usudwriad � to foregtluw ttBEneat and w10 }i` u T?I►S iNI"UM[NT WAS-DIRAFTRo By a. 1 • , r .�,.�lf4Tls�Xa•HNXl►'RSi��i.Sri b Mut�ay_ .. , ,�(�j ; �� � ���� ��. r g. ��. !.. :Notary lr .: .. F a►a js autheAtiated or *dcnswiedged: Both My Co m i� ► 1�(If not, itapt{ , date: �'ti'r ,. ,, f;rRw�9+'Orin*below their rleiatutrs. At H H a 9TC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT c St . Croix County z cy 4 a H OWNER/BUYER ���M I/!� ,� M ROUTE/BOX NUMBER Z5o se- Fire Number .CITY/STATE #,kd1.bo kk L.A) r ZIP S�d ljo i PROPERTY LOCATION: �e) k, s� 3t, Section - , T y N , R-as Town of H4-/S&nn , St . Croix County, SubdivisioO",0 /"^"`►� 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- ment 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. H 0 E I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Offkge within 30 days of the three year expiration date. SIGNE DATE *2^ � 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 . ) • ' SAFETY& BUILDINGS DEPARTMENT OF REPORT ON SOIL BORINGS AND DIVISION INQUSTRY', p �+ LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS _ (1-163.0911)&Chapter 145.045) LOCATIONS SECTION: TOWNSHIP/ �NO.:BL=NO.: S��V I$jl,ON NAME: k� '/- '/4 a IP47 H/Ri+ @ 10� COUNTY: OWNER'S BUYER'S NAME: MAI LI NU ADDRESS: f� C"(Ix. SHIM /"!,`l/ems- o&, ,0r'ook Xd, s0� �s• S vl USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL ESCRIPTION: PROFI LE DES RIPTIONS: P ION TESTS: Residence d ANew ❑Replace I L�_�0 RATING:S=Site suitable for system U=Site unsuitable for system �G 5- 4 * f NIS VENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-IN TANK:RECOMMENDED SYSTEM (o tional) ❑U D S ❑U I s DU ❑s au E]s ©U cv,�� e,�g ,� �a•x sa If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: /V� Floodplain,indicate Floodplain elevation: /u PROFI E DESCRIPTIONS BORING TOTAL1 DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTI-14 t; ELEVATION OBSERVED EST.HIG HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- g,v /oJ.9' /�lo a .� g,v' I / /s o s 07 r B- 2- r.o, /at. Z` a,4 er 7 �,� ' i+. owl 1. 2 .4A /.2 Am 0, 3,7 & S - B- Y .v 162.7 ' /t,10,4-t e 7 . Or • 5111- h-19al Ij Bft GS B S B--C d • /o/. 9 ' o�.c /� 8�0 ` Ap 611, 40 9,k .S' /S 3 3 B C.S. S B- PERCOLATION TESTS TEST DEPTHIF WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE PER INCH ES NUMBER 44911ES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 P_ I ')• Aid 3 6 G3 P_ Y 3 ZVO 3 6 <3 P- 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 76. 9, ' /0 .5,�/�g ..........,.m..... .._ i .....,.... ...._� — < o-/4 0 , _ 61^ Ot � — N e ;. t es f _. } A t , `� 1 f i 7 _.. ..__ __ ._ __ _�__._.__ �...-__ ... __ .._3..�__ .. ; �# ,tl�,te� SA 1.4 C-fi gra�,ra! ,BIa-!33o MA��fa►`.• lJe.-�.•cA/ Ocff4 �eaCC:re,�c.�fs I,the undersigned,hereby certify that the soil tests reported on this m w re made by me in accord with the procedures an 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: ,O4t A4-f • o� v f141Gu 5-- - )DRESS: / CERTIFICATION NUMBER: PHONE NUMBER(optional): l!(� ,9u-�ej ve dlon►� Gt/,3 S��OC(, /�� NJ_3d1G S1'd' CST TUBE: • c e ION:Original and one copy to Local Authority,Property Owner and Soil Tester. -6395 (R.02/82) —OVER — 1 c • � r INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 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; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a 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 us() 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 not apply, place NV 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 WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stor3e (over 10") BR Bedrock cob Cobble (3- 10") SS Sandstone gr -- Gravel (under 3") LS - Limestone s - Sand HGW - High Groundwater cs Coarse Sand Perc -- Percolation Rate reed s - Medium Sand W -- Well I's -- Fine Sand Bldg - Building is - Loamy Sand > - Greater Than psi -- Sandy Loam < ..- Less Than 1 Loam Bn -- Brovvn sil Silt Loarn BI BPack si Sill: Gy - Gray cl - Clay Loarn Y - Yel1m," scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot Mettles sc - Sandy Clay, w% - vrit11 sic - Silty Clay fff few, Finiv,faint _ c -- Clay t;L; -- corTSmon, coarse P1 Peat I I 1� rnm -- Many, medium m - Muck: d - distinct �. p - prominent HWL High water level, Six general soil textures surface water- for liquid waste disposal � � 3M - Bench Mark VRP Vertical Reference Point i TO THE OWNER: This soil tesi report is the first step in securing a sanitary permit. The county cir the Depart.3sent may request verif cafion of this soil test in the field prior to per mit issuance, A complete set of for the private sewaje syster;t and a permit application must be submitted to The appropriwe local in order to Obtain a r)ei mit. The sanitary permit must be..tamed an(,' posted prior to the of any coi)s=ruction, o �� II tit It AV � 7 Sd-LCbs L0. KtriNS got r Ll J 4y fez / O �•`' Nofc : S.ri�(1 L a`C- -�,� h a- `l?.�d� a r p u.K �' Co NO- . d ...r rr �J •J � I y vr .� w A d • a-y N •�- c. ! =r ,� V1 . I > • • O 1 �n- J v+ •�, ..� ,c J H r J,