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HomeMy WebLinkAbout020-1153-50-000 \ 0 D « K 0 \ 2ck % / � & � § U) 4 DT R �a cc } C2§0 & CL I-7 _ =n ■ fa .8 Z .0 ~ )/ _� §/ { _ � © � ■ k $=f ° E = - : eke c «% m 0. § Cl) � ) � w K 2 CO % M j § .. � \ 2 . � $ 7 S { 2 @ � k } � < ■ .. k / J L 4 � , - ■ � � ; > 0 2 ) I ) / k EL o . m f a a a IL ° ' j � k ) > § k 1 0) � � 7 co to co ■ p ■ J E -K J g ) 7 § o ff R { , ■ a }S / J 1� § § k o } k ask � C k" a » Cd E � ' a § / 0 a o & U � ,. , Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �_Am O. -D pk ) TOWNSHIP r I U G� S ON SEC. T N-R�© ADDRESS { o'� VA 1 )1�kA ST. CROIX COUNTY, WISCONSIN SUBDIVISION 12Y LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM x U' _�R e (0 5x 6�K1z"A t0' �a a' C IelJiv&(A l r � S �U G I � ' O , (� Pak INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used I �1be. 1 N qR of /l '\D � //\\ b Elevation of vertical reference point: . 0 Proposed slope at site: �v SEPTIC TANK: Manufacturer: e k s Liquid Capacity: UO CiA Number of rings used: a��� Tank manhole cover elevation: l - I Tank Inlet Elevation: 105. 0 Tank Outlet Elevation: 10 Number of feet from nearest Road: Front,O Side, Rear, O p� feet From nearest property line Front 10 Side,O Rear,O feet Number of feet from: well q S building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE Nepf"�Ca E-�, 1 �a 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).56t : -6 JQd.s 6 -�S U -70 I SOIL ABSORPTION SYSTEM 'o Bed: Trench: -5x 6/ (-'01WI-P-QMC' Width: S Length: V Number of Lines: 3 Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, , O Side, O Rear,t—\)rFt . / Number of feet from well: QD 0 Number of feet from building: (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: C Inspector: Dated: J I (y Plumber on job: License Number: 3/84:mj = HR SANITARY PERMIT APPLICATION COU TY In accord with ILHR 83.05,Wis.Adm.Code �jt- CROIX 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 ® NO PROPERTY OWNER PROPERTY LOCATION DA N WN4 5 f '/4, S Tc , N, R E (or) PROPERTY OWNER' AILI G ADD SS LOT NUMBER B SU IVISION A E C Is 1\1 C TY,S ATE ZIP C DE PHONE NUMBER CITY TARE T ROAD,LAKR OR NDMARK Wj TOAN Rk lQu _DFQ VQ ��S ,� O ❑ VILLAGE: r• II. TYPE OF BUILDING OR USE SERVED:. ` w,Tk Dgop 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. A New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. , IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. X Seepage Trench c. ❑seepage 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): Feet PKPrivate ❑Joint El Public VI. TANK CAPACITYIJ V 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 loo o '1Z K_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): Plumb is Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: kickAR UA, l UV 96d,110 PI tuber's Address(Street,Ci State,Zip Code): _ Name f Desi ner: Q i ^b Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)N e CST# f! C I CST's ADDRESS(Stree, ity, late, o e) Phone ENumber:kuhw� L SqCIG IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate IsM;JA/i' nt Signature(No Stamps) IFA Approved ❑ Owner Given Initial f�7�� Charge Fee Adverse Determination / i r . rl r �'X. COMMENTS/REASONS FOR DISAPPROVAL: C�� 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 • r 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 property 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 8 115 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 in: can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re0S+trB 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. 0 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. -----------------------------------------c --------------------------------------- Owner of property , a we-,5 D. .lJcL-tl— L— Location of property Ajuc/_1/4 --�E /4, Section 2—?Z_, T_,a I( N-R P-7 W Township UGf'SD/l/ Mailing address Address of site _P_77 BrarJ lei OYiy _ 14t' dsex-' Subdivision name Lot number Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is thl property being developed resale (spec house)? Yes No Volume _ and Page Number✓% <5 .` 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. ; 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. 1121— Z 2 5f) . V QAAAJJ===Z- ZaAQl S' n tune of Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature DQCUMENT NO. ^ WARRANTY DEED n STATE OF WISCONSIN—FORM I BOOK 80 f Au1 g 43G224 THIS SPACE p6BERVED FOR RECORDING DATA REGISTER'S OFFICE ST. CROIX CO., WI THIS INDENTURE, Made this--.2nd .. day of.........l:.eb1.UdKY .8 , A. D. 19 ., between ,_._terld ts...Irl......_. Ree,d for Record p is cca[tanon, and-.each..in..his..a3eui_right---------------•-••--•------•--..................... APR 4 19vB ....................-........................................................................................._............................ ......._................................................................-.......part...i,.ea_ of the first part, and at 4:00 PM singJ s--p�xQil----------------••--------•---•-----•--- ------------------- V ------•-•---------•----------------••-•-•----.........................................................._....................----•-••---- RophtN of Deoeb ..........._............................._...........-............................part.Y......... of the second part, Witnesseth, That the said part..125... of the first art, for and in consideration - ------ ----- --- -- p -- � of the sum of..SiXte.en '�hQPLidAd._dnd..NQ/1QO .Dollars _ RFTURN To ----------------------------------------------------- ---•---- -------------------------••--_ kl]t -- to..._ M....... in hand paid by the said part..Y.._... of the second part, the receipt, _.._. ____.___ __ ______ ____ J whereof is hereby confessed and acknowledged, ha.Vg... given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do.......... give, grant, bargain, sell, remise, release, alien, convey, and confirm unto the said part--- of the second part...................h S................. heirs and assigns forever, the following described real estate, situated in the County oL.-..........................................._. and State of Wisconsin, to-wit: Lot 30, First Addition to Fox Valley, according to the Plat thereof filed March 9, 1982, in Volume 4 of Plats, page 98, Document #376101 , in the office i; of the Register of Deeds for St, Croix County, Wisconsin, Together with and subject to easements, covenants, reservations and restrictions , of record. j I I li I! (IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE BIDE) Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part...1.e's. of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. To Have and to Hold the said premises as above described with the hereditaments and appurtenances, unto the said part...Y...... of the second part, and to......._....hi;3............................... heirs and assigns FOREVER. And the said ...... .....irm lair .. D..oQt?�I11Ql. --and......----•-•------ each..in_.h� eSom.xa ght�..-•--------------------------------------------•---------------•---......----•----...-•-----------•--------••---------------.................. for.......................tlleix.........................._. heirs, executors and administrators, do........-- covenant, grant, bargain, and agree to and with the said part...fit....... of the second part, ......._..h1.5.......... heirs and assigns, that at the time of the g y p ............._... well seized of the premises above described, as of a ensealin and deliver of these presents sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever, .......-.............-............................................................................................. •---•--------•-------•-•-------•-•-----•----•-----------•----------------_--..-•-----------•------._-------•--•---•-•-•-------•----••----------•--•-•-----------..---•----•-•-------------------•-----•-- and that the above bargained premises in the quiet and peaceable possession of the said part....Y..... of the second part, ....111.5............. heirs and assigns, against all and every person or persons lawfully claiming the whole or any part thereof. ........................ will forever WARRANT AND DEFEND. In Witness Whereof, the said part..i eS.._ of the first part hate....... hereunto set .._....their....... hand_S-- and seal.-S_. this..........11th........... day of------fQbrUdX..............—A 19 88 1 jSIGNED AND SEALED IN PRESENCE OF "" "" """"'_""1"-----•-----_---•-------•-••--•--•--------•-----•`-' ---•---•(SEAL) ....- (SEAL) !'I --------------------- (SEAL) i -- i �j ----------- ----------- ---_-------_---_---(SEAL) J State of Minnesota [��si} tnn_-.--.___. County. Personally came before me, this......17th day of-__•-__Egbruary A; D., 19...88, the above named _�?nk"-LaPlant= tenants in comrion and each i I hi&--ewn--right �_..... - to me known to be the person_?- who executed the foregoing,P strument and acknowledged the same. t i t ` n . ' THIS INSTRUMENT WAS DRAFTED BY - " � - -- NOTARY '"'�w J01=iN_L _'"1I`�RELL John & Kay, Inc. SEAT. Notary Publi ;;" ►t ki4d�I�......,;.:.�S�County, MN. 7582 Currell Blvd _ �1!t ASHINGTON COUNTY Woodbury, MN 55125�— 1`ty c,>mmission _ . �iy ommtss)un I=x urs�lun 'za rsfst3 ............... (Section 59.51 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly printed or typewritten thereon the names of the orantors, grantees, witnesses and notary. Section 59.513 similarly requires that the name of the person who, or Severe. mental agency which, drafted such instrument, shall be printed, typewritten, stamped or written thereon in a legible manner.) STATE OV WISCONSIN Wisconsin Legal Blank Cnmpany WARRANTY DEED FORM No. 1 Mllwankor wiv (Job Ik1 R w7 ) _ y UIIPLRTTED OW ED Y 07Ne R9 6�9 4 r er '• . T 24 IT J•J �C r 1 f \� �Q•Y� JI Uv LOT 25 [®. (•+• �.,r�ior� r � �' ?+r .� �" .x�=-�--_ •��9y1� f 161 � e.s2 a 7�t •°t � °rI pr Q '�• Y'w.� +,.fir \ ...J / � 11 .���ppi1 �1�� i •� �.,,�, .'�_��-_/�.- •+`-- - - \�+t���i--"•�_�.NJ1–`�_°__'^�, ­Lor7,' : i �,� 1`1�TI,• .e,. 8.847 . • ;�D �V • 1.1 d' 1R•S :A I , ' yr• '• /n� ,) ° ° ,' 8,, %7�_{ 7 32 ;aid 11 r-1 �-- eE• .r. 1 � t i 11 ��/"Q-� ,/,/J 1�' t v. .? tp�r 'FM4•r. ,.4.� t' r,+�I` r Ta � ` ►.,sl �' 6/ t'd•���s3° � �'� •�� .ail �Lor.6A . 1 nor s r kit- Dr 40 R ,11 yam.,.;'+�. mow:.. 1�:�.•��) A• • ..v nJRTh, .t ' Via•. 5c, -- uHVCgTTt L N • Y . STC - 105 r Y SEPTIC TANK MAIN'T'ENANCE AGREEMENT St . Croix County o , l OWNER/BUYER COQ UYL S yCJ �s'( m ROUTE/BOX NUMBER Fire Number CITY/SPATE ,b� 2,45e vv f lit f S _ZIP PROPERTY LOCATION : 4 , 1 3 i M R�-70W ,��^"� ,:,. .Sec t iun�_ Town of ¢udsC,Z/ St . Croix County , Subdivision %hex P�x116U Lot number_. Improper use and maintenance of your suptic syste in. could result in ; its premature - failure ' to- handle wastes . ­., 1 ruper` maintenance can silts of pumping, out the septic tank every three ,'years or sooner, R , if needed , by a licensed septic .tank "L W!IaC you •put intu the system can affect ` the function of the- Septic tifnk as a ` treat - meat stage in the waste, disposal system . •_ St . Croix . Cuunty- residents' ma •be• eligible to t,ecuiv� u. grain lur ' a maximum of `60% of they coast of 'repl.�ccurEnt'� ol a failing sys.tew, which, was in °operation' prior to July 1 ,'µ i978 St r Croix'' Goirnty accelite'd this 'hrubram*slnAuL;ustso f.;:198U', wi:;tl;ty the ;ruqulr'cmua.t'- thatiq ' owner s.'-of, all`,new",syst Vin s ',ai,re"e to keep th�rr s,ysteins pro,per'ly �" = maintained x s. The prupurty owner agrees to submit to .St '. Crui,x'�Couuty `zo►iing a ` certification form, Signed by the owner; and by. a master plumh_er, journeyman plumber-, re.stric Led-:plumber ur., a ".lic'ensed .pumper. veri- fying . that ' (1) the on-'site wastewater di5pu'sal '"system is' in ?pruper 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 : :' 0 I/WE , the undersigned , have read the above requirements :and agree to maintain the'' priva.te sewage disposal system in accordance with X Che• standards set forth ,` herein, as set by the Wisconsin Depart ro ment• of Natural Resources . Cercification form must be completed Crbix 'County Zo , -days and returned to the ning` Uff= 30 i ` ear expiration : date . of the three, y X: S CNEll . ll A T E St . Cljoix- County Zoning, Office R. O. f•o x 96 Hammond , WI 54015 715-7S:6-2239 or 715-425-8363 Sign ; date and . return to above :address . G• oG Z DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, ' DIVISION LABOR-AN REDATIONS PERCOLATION TESTS (115) MADISON WOI 7969 (H63.090)&Chapter 145.045) ,� �� / s;/ N/Ri L( 1 T�UDfO�. �t?`BLK.NO.: SUB pl�✓ION(fL� CO NTY: MA L ADDR SS: 5y 40/ U+4fe -5 d —D,4kL �S�- roc%�s f/vp�o,✓ wiJ . USE DATES OBSERVATIONS MADE CO DESCRIPTION: PR F P O �D TESTS: J fRNew I15--/ fQ 22 JPF RATING:S•Site suitable for system U-Site unsuitable for system . MD: IN-GROUND-PRESSURE: S ;IN-FILL HOLDtNGNK:R MMENDED SYSTEM:E S [:]U Q S QU _ U o S � t �S ©U 7A_ !� If Percolation Tests are NOT required DESIGN RATE: eQ ss � If any portion of the tested area is in the under s.H63.09(5)(b),indicate: I4s..� Floodpl indicate Floodplain elevation: PROFILE DESCRIPTIONS /A/ -A+ - o� BORING AL P R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERV D EST.HIGH EST TO BEDROCK IF OBSERVED(SEE ABBR'V.ON BACK.) SD UE�' s-y S I lt ,y�' > S ' �o • r,�Q�,. /s o ' R� sc s��- e - � B-3 If.0 ' �1 P�' /.O .. /S /. Z ,p ' �a �o ' 1� Q f ' ' s (0,t w �7 d�0' � � �' /Z. Q � /�O ' B/k s/ /,G7 ' N • cooR s •3,� /��✓Sea y i 04 3.6 'f4AI wJ ' '~ p r �' PERCOLATION TESTS T1,o �S . FT • Vol Ir A Lt m o . TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P RI D 1 PERIOD 2 PER INCH O P. N P-. P. P- isLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- tontal and vertical elevation 'eference Ints and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent O of land slope. / � ) �.�� %�OZz�� '70, 7 � SYSTEM ELEVATION ow T�'fti s 00 , 0 777 71 i11 �Pv/ C7 , lAr cl I- - p��....—.. .�w: G L J _ I I T 11,E ---- 1,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 1print): TESTS WERE C M��D ONj�� � 655 O'NEIL RD.,HUDSON,WIS.54016 QNGWT AD CERT FICATION NUMBER: PHO NUMB FR(optional): WAS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. Z Y? �--- 6 CST SIGNATURE 'e NSTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. 151LHf34R[-A.*A5 IR.n2mi _ _n%/FR s x, o po Izz rb O � L ti - r• C m � v► m H a r oS�S � � I - --— - ��06_ Sits - - - - - --� O• v a � � Mbri oa o � \ � m m c: N I!► � pn g _ [?.Q. L. 67 PL OT OS 5 E C ION P 1-3 0 J EC T D/I A. ;;NAME E TrArn o,5 n X- N NAM 12 • L 0 CAT 10 LIC ENS E -X-Jjil I--q- S T E no, C PLO P .4 F1.0 Lot, D 4-1he,63 P7 A).50 -rk?NjrAt5 pa Z BAd 1,0't FOKR 5 Xz RKt PipPes set 0 As $M-+ tft - k-A XPI 16-70 kook D P box Ek: L/1 YS I -QO )A 0 es. Foot of �► . � . R�.k used uN�t� U RK 5AI `,` Lev.= loo.o /a, UZ11 '1_5 fuXcr iWj ua Act lid 33zop tt zlb ARP, A0 M F— K - —--------------- 0.,ve R 3ool IA)esf L.ot t e FRESH AID. INLETS` AND OBSERVA110N PIPE CROSS SECTION ROO A roved Ven - Cap Low IS e -�Jk IONC,65 Minimum 12" Above Final Gr de--�L AX 4" Cast Iron Above Pipe Vent Pipe To rinal Grade-- Marsh Hay Or Synthetic Coverl.1 ,g Min. .2" Aggrog Over Pipe Tee Distribut i24>. • Pipe Q5 Aggregate Perforated Pipe Below g9.0 Ke"A -minating 7N '70 Tpupch Bencath Pipe -Coupling Tex 70. Bottom of System 1/yOtp rTEO OWNDCG by OrMC45 l';'I•V 1 \ ♦. 1p I • V °Y�♦ LOT f1 , - 1� l/ �� ,r ,.. •s'Jt. . t' �/� � a... 3.6L N ` da O 'iP�' � •W LOT r7 LOT b l � 3.3.38 3.�.R °�'A ,y �•••! `� •~ ry'�` �• '• 3 �►' ' ` ,�•1:7.. � ° ` •�r � rte. .. �.,_,i �,. � / .� •. LIT to .� '�- •— -' •• r�• W. YP IV 17•.,i-y •�'•�• Z r r 0•,� •�;•' '`' �c,�11 ,�,tills ��••r � �'�M a. ?r' __ r• ♦. �' � r' 1`� d �"`�;?; A 1 Nit LOT K i• �'` > ; 1, r /o Via',':. " °f 4 Lor Jr \ r j O te. I 'Y 3.00 R / 4 cor a �Kl y r--•rte. u r o • r • • .N. 1 � o�L s ,• J 1�,, •, r � .•y, 1 T ,£ cor r' ss X. �• ""1 tat •\ ^�,�� 1 �� fir.- ,4;'. . a4. .r•�4 ............. ... . K ..._ ► grYalr 3.11 fL \ •`r . ,,,`:� ~ ....LeT t .�. JM�!t.'P ,1. � 0•r ��: :.Nlt Ji !NL F 11 Jf f °rr I �. ; i ,• guf...t f.9 ,�•>isr, low I. .. ......� i. J'46 r V. .a.SCJ. pDLF1NdS ROiID - j—_. �• -- ------------- ----- — — .I UNPLRTrEO OWNED BY orNE45 •