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HomeMy WebLinkAbout028-1013-60-200 Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP �j,,�r Tvx SEC. 1� T N-R W ADDRESS /�� �7� �oo TN ST_ ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IMR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /1/oitTH �itop�7Y LI/v,E 5 5/ pvE2 300� vsivTf C&UTr/t L2zvE ALO :S7Ae i pF AOO Tip/,ST /+'1 h.�"S7 A.p427>' Ly' &'V.=.I Top 0';: A't0A 13D>, 13nTWA ,!'TBA AT ./✓6274 S JooF ° i rLE✓.=JDO,00' 39' ,rro.f T /i'20&47'y �x2SYSw[a T/2AP ,Ooo2 f,.ZivF ExzrrtNLi R6r=�ni�E v✓�2 3on'fiurn LING INDICATE NORTH ARROW wtcL //D 'PCALE �XLSLTn✓G /.�2z✓Ew�Y BENCHMARK: Describe the vertical reference point used r,rr f � dF - A f TQo10 Elevation of vertical reference point: /ljd, �„ Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: zlo p GiOi Number of rings used: �_ Tank manhole cover elevation: Tank Inlet Elevation: 9 ! 3 Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,(D Rear, O feet From nearest property line F ront, Side,®Rear,0 SY feet O Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I 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,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: a� Lenalth: / Number of Lines:_ Area Built: Fill depth to top of pipe: Zi.,,. 724,r& 42=2 Y " Number of feet from nearest property line: Front, O Side, O Rear,®pt .�_ Number of feet from well: 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, OFt. 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 - - 1 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION MADISON,,W WI 53707 P.O. BOA BUREAU OF PLUMBING `; SEi,N0,,S1 1,T28N-R17(U CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number Town 06 Rush. Riven ❑Holding Tank ❑ In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTION D TE: Mike Van Kunen Route 2, 472 200th. StAee t, Patdwin, G/1 5 002 /C) j (_ g�r �� BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV. Name M Plumbe,. MP/MPRSW No.. County Sanitary Permit Number: Gatcy Zappa 3300 St. Ct oix 112836 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PR OVIDED. PROVIDED' ❑YES E NO ❑YES ENO BEDDING VENT CIA.: VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY WELL: IBU I LDING. VENT TO FRESH ALARM FEET FROM LINE: AIR INLET. DYES ONO ❑YES LINO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED_. PROVIDED: ❑YES ❑NO ❑YES ❑NO I ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH JDIAMIETIR 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: BED/TRENCH WIDTH LENGTH IN11,111"'S D157R PIPE SPACING COVER =LIE DIA ti PIT$ LIQUID iHNC MATERIAL' DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH I".' PIPF DISTR PIPE DISTR.PIPE MA RIAL. NO DISTR. NUMBER OF PROPERTY WELL. BUILDING VENT TO FRESH BF LOW PIPES ABOVE COVER ELEV "ILF F ELEV END PIPES FEET FROM LINE AIR INLET: NEAREST-1 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSY SYSTEM EM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ' ❑ SOIL COVER TEXTURE PERMANENT MAHKEHS OBSERVATION WELLS 1-1 YES 1:1 NO DYES ONO UEP 7I1 OVER 7HFNC11 BED DEPTH OVER TRENCH.BEO D SEEDED MULCHED CE NTER EDGES ❑YES ❑NO 1:1 YES ONO DYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIOTH LENGTH NO.OF LATERAL SPACING 16RAVILDIP1111111LOWPIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV ELFV DIA. ELEV. PIPES DIA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES LINO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE ❑YES ❑NO ❑YES ❑NO INEAREST—�� S ketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE DILHR SBD 6710(R.01/82) Zoning Admcnisttatotc DILHR SANITARY PERMIT APPLICATION COUNTY , CD/ In accord with ILHR 83.05,Wis.Adm.Code ° STATE SANITARY SANI P RMIT# //,v? ?3(o —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 NA I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES LO�J NO PROPERTY OWNER PROPERTY LOCATION ��_ % %, S T , N, R E(or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK VILLAGE: II. TYPE O BUILDING OR USE SERVED: -- - 0 a /0 43 - 010 Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check##2,3 or 4,if applicable) i 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. N 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. 9 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 ®Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App structed Tanks I Tanks El Septic Tank or Holding Tank p,3 _ c> EJ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ F-0 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 Stamps) -MP/MPRSW No.: Business Phone Number: PT-umber ' Address(Pirifet,City,State,Zip Code): Name of Designer: I VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# qG� oL CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ��y/ ❑ Disapproved Sanitary Permit Fee Groundwater ate I,,,���sss���ing Agent Signature(No Stamps) LYApproved ❑ Owner Given Initial QD 1 2 C o arge Fee /a20- ' (l r Adverse Determination t{�`/'r r"hh / u 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 j 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 most 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'/2 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 ['t'S e can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re SUff is used in your building is returned to the groundwater through your soil absorption e 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) 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. ------------------------------------------------------------------------------- .uyce ! � � rawer of property � Ww/, Location of property 1/4 AIJ5' 1/4, Section // , TAN-R_L7 W Township, E7--2 Mailing address 7. X72 ZOO 7 12L !? O/w/n! wy-, �aodz Address of site -,"JAM Subdivision name AIA Lot number AAA P=ev=6 of property /yIA�L�h ��2KEL50/ll Total size of parcel A Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes ✓ No Volume and Page Number 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 y e ster of Deeds, as Document No. S'gn t ewnef- gLtyF,e Signature of Co (If Applicable) 1uyk-lc h DGt"� Date f ignature Date of Signature ,r r 'rod rdAd SAVINGS OF LACROSSE Michael & Connie Van Keuren 9/29/88 Rt 5, 236 Jersey Rd. River Falls, WI. 54022 We are pleased to advise you that your loan request has been approved by our Board of Directors. Funds have been committed as follows: Loan Amount $47,200.00 Term 360 Interest Rate 10.375 Closing Costs (refer to Good Faith Estimate) The following conditions must be complied with before closing the loan: (X) Title Insurance must be obtained showing merchantable title. or (X) An Abstract of Title continued to date with an attorney's opinion showing merchantable title. (X) Bring to the loan closing the following insurance binder or policy with the mortgage clause to First Federal (X) Fire and Extended Coverage or Homeowners police ( ) Flood Insurance 4 .. .. ()o The seller or realtor must provide a Warranty Deed and completed Real Estate Transfer Return transferring title to you tq,gether with any other documents necessary to clear title. ( ) If the property being purchased is presently rented out, state law may require an energy audit prior to title transfer. Please check with your realtor or loan underwriter for further information. We must be in receipt of your completed employment and deposit verifications substantiating information you have stated to us. Please remit to us your I % commitment fee of $ 472.00 within seven days from the date of this letter. If we do not received this fee, which is non-refundable, there is no commitment. A self-addressed envelope is enclosed for your convenience. The terms and conditions of this loan commitment expire thirty (30) days from the date hereon. If an extension is required, the terms of the loan are subject to change. .r Please feel free to call us fo.rtadditional information. Please see Attached Additional FIRST FEDERAL SAVINGS AND LOAN Requirements �> SASS IATION OF LA CROS �4 First Federal Savings&Loan Association:of La Grosse 605 State St. LaCrosse,Wisconsin 54601 (608)784-80M FF05-070 ' STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County Bi /BUYER /t�/�C .�PAIAJ/I____ 11� ROUTE/BOX NUMBER Z �tZZ 2�Z� r� FIRE NO. i1?L _ CITY/STATE AT ZIP PROPERTY LOCATION: yE 1/4 IVC /4, Section /I , Town of lZGfSif /tle? , St. Croix County, T- Subdivision A1k , Lot No. Y 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 Zonin Office within 30 days of the three year expiration date. SIGNED DATE `D 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 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS 1 INDUS?9Y, LUMA RE PERCOLATION TESTS (115) • �y � °f MADISON WI 53 07 HUMAN RELATIONS (H63.090)& Chapter 145.045) A I N. TOWNSHIP/�: OT NO.:BLK.NO.: SUBDIVISION NAME: SE �/ '/ �� /T 'N/R 17 E(or)W ��s f+ R PAR aF o 196tC �i.�A-, COUNTY: . OWN S R'S NAME: IMAI LIN ADD SS: S�. Ckf/x AlWlrf 7'04eC/sot/ PY• 2 i?aX 11,? TAIPWi-v 41/ S. USE DATES OBSERVATIONS MADE NO.BEDR Q AL DESCRIPTION: P I O 7 S: A STS: Residence ❑New Replace I ��- I�► / DES 1/- ! ;5 RATING:S-Site suitable for system U-Site unsuitable for system ONVENT L: NA MOUND: IN- PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) OS []U DS ❑� -CJS E111 OS DU I r,Pfv�hlS ovc — 3�10� ,t•,•,vi.y v,+,, i q ' G(i O S Q � F r If Percolation Tests are NOT required DESIGN RATE: i If any portion of the tested area is in the under s.H63.09151(b),indicate: A�S I Floodplain, indicate Floodplain elevation: —� PROFILE DESCRIPTIONS A, "DECiA44C ,C7- BORING TOTAL EPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES .f IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) r _ ' S ! 3,3 ' rxIl?B- 95r0' 6' a 1(D' i-1 1a - S : o- C-I B a tl,r . S -� 611Z . w ,-ff,. S I I - 6 r &•o '-i a 7.0 ' ;aE yQ�Fy Nottito s C fEW �'rsTr'..i�T B- 00-Ur 140*5 > /o" lg//- s,/ /6,7' S/ 33 " T'l.v 7rw S B- • B-3 //,o� 9f ?z > �/o ' s' o�- 4?,, 511 ,e,? 'e,-fy - ,,. s , 3.0 G 7 B�wo v ycRS °r .v, 74A,1 71,112P B- S ti S'7,0 T.tS wipe PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t --PERIOD PER INCH P. / ,p Ao 2- 3 ly Z, S P- P- 2, Z P- P- C,• U / 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. r SYSTEM ELEVATION -071 P P'0d I/1'o X 716 i I REF USL-0 To M,4X i mot,2,C S I•Dt 1 13 So P P $-/6,0 A., PMVAg !E V30- Q+taD Di ff-efPe�,vT TEIxTVPES d;F 'S0 S'rRUC'-f aRt -- - - ! N sois �ri6w �, D E',� fo /�-t ��ij' srTV,p r-�v �� Af6viog R A,✓ /,v -yAOJV Wp o v f Sy 9'7-E,*1 ,r "0-4l 11.90S6"11 9I.la^ G /-T" &Y4cT ewr mt, I-y v_-4,5 r-oo° P/ST-tNre- , To 13 4ov// 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(print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. ADDRESS: ' CERTIFICAT N NUMBER: PHONE NUM ER(optional): ROBERT ULBRIGHT 2 y�Z v ►a,NN.INSTALLER 8 DESIGNER LIC.NO.00663 CST SIC NATURE: ISTRIBUTION: Original and one copy to Local Authority,Prohm I v Owner and Soil Tester. lillwrz;e ILHA-SBD-6395 (R.02/82) ;,,-R �� 3x°F. Nv i�OST • l _ PA6— of Z REPORT ON SOIL 13ORiNGS ; PERCOLATION TESTS f 15 ' ' e Poor PLAN PRoTEC i r. D. ./MP /% pA rE f? HOMESITE TESTING CO. ITT.3, O'NEIL ROAD BOB ULbRic;;� AUDSONt WIS. 54016 CST' S 5757 ►0 2'YeZ r PROPOSED HOUSE Mosr L.IF Z� FT o f Moofe "a-4f 46i- TEST ier.45. PRo POSED WELL M VSr LIE 50 "' of t1ooE FiPOH ��L TEsr �9�E�fs, • = 4i4t�'/f�OiE P�Tf � = EXIST/�t1(r I,�ELG 1( at Aetw /oc'fTiowf a HANp Ro9EQE0 ow s4twrL Boers • ' yorit . 6 M REFERtNCA- PoiaT' !o,4 OF Z20-/-r0 �60 41a . Ooove LEGEND Pe,, Pr /00, o " �CA' O LIA)f AND ' ,(MrA)t %10 ' ID iv-ops • � � �}x 33 tl o Q E � 0,1E o)d- SDW �nQ SH^U i uo� FL�ST Al 7- P,)D-r x r JT/ ��C Two pL�v�S AI&7-g- Exlsrs'NG Fia2Leo CESSPooL �wy. To Lo D mAoYE6 .SLOPE \ pal � Q SO. 3' '1 C'�n:TE2 L7"vE' S' OF g00 TN. ST_ / .PTNCrIS ovt2 300 F1w.. `WEST /hvi*rATY p L=NG r- 1 11101-W6 SI..fEP 900 y'E FLUEA-r LINE /� s[a4f RCZ/ 4 c-EI)7,61 T SXJ7',51Y! /\)Eh/ looO &L. SEMMc. 7AYv1C ° \ O I ' A133 To t, ^l OF �iIJN /�A S7 CAO.2x Co NniTY ,f7EP s97- Y C.T. 906 .SEtn/E& ELrv.- /oo.oc' FX2STSivv -I;wGP L7ao2 Ex21rs JG /�tS24F:vGE n/orE: EXSST�n/b GALAl�k To BE .Sv4-cu-r -0 O✓E& TrtFNCN A A&fA 7'ne aG/,r A To /A T//&r-)WJFS/T OF j AC,G. /2EL01✓ M. T. PSIoC JLOPING Tb I D,1 T yxcw CS 7iicnicH 13 To llAv-9 P_S'Lor°1�G To I" 77acX)vESl so1nTN PMPUTY LZVJ L fuT /7<o/�D2TY LSrv£ 1 CxssT= Ex=S7itic A/U SCALE WELL NG IvtwAY \ FRESH AIR WLET AMP OBSERVATION POPE FINAL GRADE 4" C-A'3T IRON VENT PIPE ?41ld? II�ILIhLS y.. �— PIPE E T•_) FINAL -_arr.u.I_-E t:1kE.SH HAY OR S.°NTHE TIC ('OVERING � � � .it`F=NSE: .i�s�/z�{ 2?OD tvtiN k►UN1 r,i=::3::aF�Ei:r�lL 1 G 1,E: OYER PIPE D ISTR le-L rfr._�Pd F'LE'E h --� TEE SOIL ]ESTINGOV: i � �o✓3r�T /�/�i2rr/�T � ELEV r T`S"Xi PED C a;�°•"FiL G&Ti= ---1 h:q IT TCA: PER _ : f_ -_ FFfEAF- FiFF 1ERF)F AiT=C ilFE FCLOS�' T .t` � ! * COUPLING TERMINATING