Loading...
HomeMy WebLinkAbout020-1190-90-000 § 2 k � � 2 � 2 � o � k � � § � � § � � ƒ � § � # � � I 2 � ) z 2 ] � 3 a « t co � \ z E m i •• o I q � $ z k k f 9 7 � \ � =0 � 2 � ) k k )_ b } ) c j z ) % E a ) § k (L E ] \ ip _ k a � \ a 2 2 k ' 0 � ¥ _ _ J � q ' § § § — — ƒ gf / w ) k z 3 \ k 4 ) . @ a- 0) E � o $£ 2 » @ ■ c § » cc § o f � ■ _ § _ ' n — — E \ ) } � E j \ k LO 2 ° ` f = k K ] ) ) m � « . 2 IEL a( a,--, _ 2 E 3 ' @ a § k U I k 0 U) Q Form - S T C - 1'04 AS BUILT SANITARY SYSTEM REPORT OWNER pit,' TOWNSHIP flu dak SEC. oZ T N-R b ADDRESS Q eel J34 k WIZ LL ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Cod r o -o ij INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used I f P, d- Elevation of vertical reference point: , % Proposed slope at site: -Z SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Z Tank manhole cover elevation: Tank Inlet Elevation: �t. Tank Outlet Elevation: q.q`�70 i Number of feet from nearest Road: Front,O Side o Rear, (p Q feet i ­ From nearest property line : Front,O Side,o Rear,Q y8 feet Number of feet from: well �, building: l -2 / •- -_-1 3/Fro/u Weev-nd10 /ifs (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size . Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Len$th: 3 {o Number of Lines: 3 Area Built:Wf s-A 7­17- Fill depth to top of pipe: z Number of feet from nearest property line: Front, O Side, O Rear, Pt . Zo f Number of feet from well: � Number of feet from building: -)-"7 / (Include distances on plot plan). SEEPAGE PIT /^ Size: IVA 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: U' Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side 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 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR 8&HUMAN.RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION L.O.80X.7969 BUREAU OF PLUMBING MADISON,WI 53707 �y,}� NA-,S(Uz,S21,T29N-R19W OY' ONVENTIONAL 1:1 ALTERNATIVE State Town db Hudson El Holding Tank ❑ In-Ground Pressure ❑Mound Lot 17 Jacoh Landing NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Mittetc Route 1, Sax 282, Hudson, G17 54016 11-15- 38 /D.'U() BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: IMP/MPRSW N,, IC-1111Y. Sanitary Permit Number: Dotkq StA hbeen 5432 St. cuix 112778 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER (� ^ PR V IIG PROVIDED �1C0-tea Q�v Po YES ❑NO ❑YES NO 17 BEDDING: VENT DIA.'. VENT MATT HIGH WATER NUMBER OF ROAD'. PROPERTY WELL: BUILDING: VENT T FRESH ALARM ! LINE n /� AIR INLET FEET❑YES ❑NO ❑YES ❑NO NEARESTOM / U( (//T/, �— DOSING CHAMBER: MANUFACTURER BEDDING. LIOUID CAPACITY PUMP MOUE1. PUMP,SIPHON MANUE ACTUREli WARNING LABEL LOCKING COVER PROVIDED PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL /( PH OPERTV WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN F R" LINE AIR wLEr. PUMP ON AND OFF) ❑YES ❑NO N > ES SOIL ABSORPTION SYSTEM.Check the soil moisture at the de th of lowln I 1 Nt T H , DiAMF TEI+ NIATt RIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease untill F©RI I the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO OF UISTH PIPE SPACING, COVEH INSIDE UTA 1PITS LIOUID BEA/TRENCH THE MAT aI L: PIT DEPTH DIMENSIONS � y " � � �!i— GRAVEL DEPTH FILL DEPTH UISTH PIPF UISTH PIPE DISTR.PIPE MATERIAL NO UISTH NUMBER OF PROP TV WELL' BUILDING'. VENT TO FRE BELOW PIPES C ( ABOVE COVER 'Ep R�EV.INLET EELLEV ENU �J PIPE S+� FE:ET FROM •- LIN O` AIR N v NEAREST'--- C�l MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM 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 SOILCOVER TEXTURE PFHMANINTMAHKIHS olasEHVAIIONwELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED D _ O EPTH OVFH TRENCH BED OLPTE/OF TOPSOIL SOUF I) SFFDED MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: ED/TRENCH NCHES WIDTH LENGTH NREO LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH AB B OVE COVER DIMENSIONS 6 I MANIFOLD PUMP MANIF OLU DISTR.PIPE MANIFOLD MATERIAL NO UISTN UISTH.PIPE UISTIi18U 710N PIPE MATERIAL&MARKING ELEV.. ELEV.. DIA. ELEV. PIPES DIA.'. ELEVATION-AND INFRIMATION HOLE SIZE HOLE SPACING CHILLED COHRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION ' PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF_ PROPERTY WELL'. BUILDING: FEET'FRO _ LINE. M �•� 0 ❑YES ❑NO ❑YES ❑NO NEAREST" .' 24 Sketch System on I 4 F�etam In co ty file for audit. Reverse Side. SIGNATU i TITLE: Zoning Adm,i.nizttcato _ DILHR SBD 6710(R.01/82) DILHR SANITARY PERMIT APPLICATION COUNTY U / Cl20/k In accord with ILHR 83.05,Wis.Adm.Code 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 I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. j ✓ FOR VARIA CE ❑YES ® NO PROPERTY OWNER PROPERTY LOCATION a_r IV aj/a S&j%, S TC�0,, N, R E (o W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,ST TE ZIP CODE PHONE NUMBER CITY ( NEAREST ROAD,LAKE OR LAN ARK S�t♦ 8� IL-25�­ ) --741? Vl NU A r.. dfb. r Vt 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. F\7 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. IN 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) t.. 1. a. See a e Bed b. ❑See a e Trench c. ❑ seepage Pit 2. P CO ATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C 3 A31-75- <�. . # 0' Feet 01 Private ❑Joint ❑ Public CAPACITY VI. TANK 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 Od O W S ✓ ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ El 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 St ps MP/MPRSW No.: Business Phone Number: �. rat P- S4-? z'/ __3z 33 Plumber's Address(Street,City,State,Zip Code): Name of Designer: 2 4-0- �t w VJL s�(a VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## "A ( / CT's ADDRESS(Street,City,State,Zip Code) Phone Number: t (Co r Ja.— -��t� `� V4 1 3-� 8 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss ing Agent Signature(No Stamps) Approved ❑ Owner Given Initial 4' Surcharge Fee 1 Adverse Determination ��'�� "�dk-� 6� I�� Q w 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 f INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION t 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: 1. 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'h 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 atec—. 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 rei suca, is used in your building is returned to the groundwater through your soil absorption o 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.03/86) 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 .Sa ,w Ow"�/ter Location of property &-) 1/4 se(/ 1/4, Section / , T 9 N-R �1 Township Mailing address OfO64� x"Asdp AT _re Address of site _ T t� (� S /�e rs, ' ; a, s °� �i<<r/�a�///'�✓ ,� Subdivision name �J-a.-ea Lot number -* / `7 Previous owner of property Have S&-- Total size of parcel e c ✓ g Date parcel was created 3 - 2 z — e- Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume and Page Number Tf- -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 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. 43 -5-4/-/37 ; 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. 3 S�!/7 ) . Signature of Owner Signature of Co-Owner (If Applicable) 4F- ,3 6) - � � Date of Signature Date of Signature . 000UMEN1 NO. WARRANTY DEED THIS SPACE REfERYEO /OR RECOROIMO DATA STATE BAR OF WISCONSIN FORM 2-1M! X35417 REGISTERS OFFICE �N �Kg4M ST. CWX 0.0 w� Virginia M,. Hanson, a single woman . . . .. . . fted for R#cW . ........ .... ...... .. .. .... ... � . . . ...... ....... . ...... ......... . . . ... ..... .. ... ......... . .... . .. ............. .. .... M 8:00 A M conveys and warrants to .. Sam.-E. Mi.11era..a..aingle man... ....... ... . V/r &1-AA .. .... MMw elOMi ... ........ . . ........................ _... ... >. .... ..... .... .. .... ... . .... .... . ... .... .. ......... ............. .. ..... ........ ... .. .. .... RETURN TO .... ... .. .......... ....... ......... .. ... . . ........... .. ........ . the following described real estate in ......St. Croix ...County, State of Wisconsin: Tax Parcel No: .............................. West Half (W1j) of the Southwest Quarter (SW4) 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, Doca No. 419479. That part of the West Half (W1j) of the Northwest Quarter (NWIZ) 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. DES This . is not.. ....... homestead property. tisit (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. Dated this OL ... .. day of . .i I ' IPt r t L, 1988. _. _... .... .... . . .. . .(SEAL) �.r,/(SEAL) • . ........ ..... ......... .... ..... ......... ......... . . ... • .Virginia.M...Hanson .... .. . . ..._ _ ........ . . ...._ (SEAL) .(SEAL) AOTS$NTICATION ACHNOWLBDOMSNT Signature(e) ............................................................ STATE OF WISCONSIN ................................................................................ ( as. \. y.SIC...I........County. authenticated this ........day of........................... 19...... Personally came before me this ...... .......day of ........(.hVN_r07t................. 19.88... the above named ................................................................................ Vir inia M. Hanson TITLE: MEMBER STATE BAR OF WISCONSIN ......................................................................... ...... (If not.............. authorised by 1 706.08, Wis. S .... .. ................ ..._.. .............._... ....... tata.) to me known to be the perpon ............ who executed the foregoin ' trument and Anowledge the same. TNtS INSTRUMENT WAS ORArTED BY VI %. ...... ..... .. ...... .. . .. .... j,Q�$.,q,..MW�ray,.,Neywood,,_Cari..�.•Murray••_ �,,(��• P..Q....Bax..229....Husil3Pn,.wL... 4016..... ............ tirota•� unljc ' (.. :� Wis. p y: _.. County, (Signatures may be authenticated or acknowledged. Both My C0 mi .4 n W gr�lt�Kr_rkt.(If not, state expiration are not necessary.) •., date: •...•.?� ..�. . ... ..... , 19�..) •r 'Nam"of Aeneas Signing in any capacity Should be type•l or print.d h.d.nw•th•it ritrnnt::m+. WAratANTT DEED STATR BAR OF WISCONSIN W mi nSin 1.sxl Ulan(. 1'... Irv. FORM Ne !— lav2 yL:u.•to, Wf-. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER_ ,' / ,�D�' y P 2— FIRE NO. CITY/STATE_�1�,�oh �� ZIP ,SAO/G PROPERTY LOCATION: N91114 S ol/ 1/4, Section -�� T�N, R /5 Town of �sh , St. Croix County, Subdivision 4 e-ez% h H el'... r , Lot No. /7 . 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. SIGNE DATE U 3 G 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) LOCATION: SECTION: TOWNS HIP/M6""2A.4L�Y: OT NO.:BLK.NO.: SUBDIV ION NAME:', w �/W/ / / 9 N/R/9I (o 1rd r /� COUNTY:� OWNER'S BUYER'S NAME: MAILING ADDRESS: ( VII �� Td�� row 1 e USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER OLATION TESTS: MR t/ XNew ❑Replace I ���/ l!� 7 'f�,y' RATING:S=Site suitable for system U=Site unsuitable for system At-e- CONVEcNTIONAL: MOUND: IN-GRnO UN�`D•PRESSUR_E: SYSTEM-(N-F-FIILLHOLDIINNG TANK:RECOMMENDED SYSTEM:(optional) 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: �(f Floodplain,indicate Floodplain elevation: � 'd PR FILE DESCRIPTIONS BORING TOTALr D PTH TO GROUNDWATER-IW4Q aE9 CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH+W ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- l 7.s ' 9 . d ' 7 7• er s� . S AA 15 B- 2— e ffh /S 7194 GS e- r s/ , 3 / /S 6.z c5 3 Al s/ �. 5/ R^ r s or B-� 7.S' /vd. 3' /�lor�c. 7 S' .6 / , S s' c B- PERCOLATION TESTS TEST DEPTHO WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER "tC"t,& AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD --PERIOD PER INCH P_ 3,7• o ,L 6 P_ Z ' 30 No 6 6 e- 3 P- 3 NO 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 a �6. l ISc,�1T-_/_': - ._Yoe a• 3 � e � - - � e w g _ d � _ i p• __TIN t � 1 _ d L i .._!� - Jkl1 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): TESTS WERE COMPLETED ON: cS a l/ii.�"vS T'� /l. .l 4 �j_AS ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional): CST ATURE: •+ DISTRIBUTION-Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) -OVER — INSTRUCTIONS FOR COMPETING 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 BASEL) ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make srAre your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. ompic-te all appi opriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (srich as flood plain,elevation)does riot 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 WITH THE LOCAL AUTHORITY WITHIN 30 CLAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Textures Other Symbols st — Stone (over 10") BR — Bedrock cob -- Cobble (3- 10") SS — Sandstone gr -- Gravel (under 3") LS - Limestone .*s — Sand HGW — High Groundwater _ .. cs — Coarse Sand Pere — Percolation Rate r reed s Medium Sand `uU — rlrleII fs Fine Sand Bldg — Building Is -- Loamy Sand > _. Greater Than sl Sarady Loarn < -- Less Than I Loam Bn Brown sil Silt Loans BI Black si Silt. Cry — Gray cl — Clay Loarn Y _ Yellow set -- Satidy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc -- Sandy Clay vv'/ — with sio — Silty Clay fff -- fete, fine, faint *c — 'Clay cc _- common, coarse P1 Peat mm Many, mediurrr m Muck d — distinct p — ptorninent HWL — High water level, Six general soil textures °` surface Water- tot, liquid waste disposal BM — Bench Mark s VRP -- Vertical Reference Point TO THE OWNER: This sail test report is the first stc.p in securing a sanitary permit. The county orthe Depar tnient may request verilication of this soil test its the field prior to pf;rr-nit issu8nce. A complete set of plans for the private 4r ale systerrr and a i ennit a;aplicat6?`1 must he sr;bmitted to the ano'crpriate local authroriiy in order to (stain a perinit, 1 ire rani€dry prrrrrit nsrrs[ be obtained and posted t,riw to the statt of anv construction. 1 � I I \ 1 y <=g—� s —�� o v o � � II I °� 4 -- L!i 0 • N � v •� d a a e M a- •� jowl • J T M .• aJ y N � d N i `� -b d I M1 m � d c �jl 3 �' `n x