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HomeMy WebLinkAbout032-1030-45-000 ti � p en I ~ I a � I b o I O N I h � I n I a I � � I Co (D c z °c LL o I � . m °' E U N co z o c C7 c I °z v c cn H r Z c E ° co S m n Q) c p m O o CD Q w zcoz 4.; o N _ Z � I CO E N p a CL M c LO a N W T p 0 0 8 � O N D O d m N N Z E Z O O 3 3 I • 3aaaa W CO 00 (n J U p rn rn z a�l O p O N M N O �1 E co O O _� y a N N w 3 ml y c o N m m ., O p N N C N CO O LO C N C c 0 a a) o o 1 Y p C p r N N O (A N co C c N C N N O W M r (n _j .- — p N ate.. 7 N N -� Z C rn O N " E .5 p v m E s • ' o (n H L cn v � E a� v� .a `ma ° 2 a cl r`I�l E 'c c 3 r A c°� a 2 o (1) c0 t c a o „ Form — ST C — 104 AS BUILT SANITARY SYSTEM REPORT i'' E� / ;,:� SEC. T , N—R�W OWNER C�G'L ,�_,�/-e.�//� TOWNSHIP �� ,� G ADDRESS - ST. CROIX COUNTY, WISCONSIN a 7 SUBDIVISION LOT LOT SIZE ` PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM �nl 1Q Cc, �3✓ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Ar C / Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: c�' Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: N ber of feet from nearest Road: Front,Q Side, Rear, O � feet //////'''""" �— nearest property line Front 10 Side,O Rear,O feet et from: well �?� / , building: ation of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE 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,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Lenth: Ir^ . Number of Lines: Area Built: r Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,O Ft .�� Number of feet from well: Number of feet from building: / (Include distances on plot plan). SEEPAGE PIT «q�, �� �5 y � 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Plumber on job: Dated: / �t License Number: i 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS I LABOR&H DIVISON HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI 53707 : N(U4-,NB%,S11,T31N-R19U1 }CONVENTIONAL ❑ State Plan I.D.Number ALTERNATIVE Ilfassigned) Town v6 SvmeAzet ❑Holding Tank ❑In-Ground Pressure ❑Mound Highway 35 NAME OF PERMIT HOLDER: MR PERMIT HOLDER: INSPECTION D TIE: LeAnne K2e,in 1 �— -d`�� // '� BENCH MARK(Permanent reference Domtl DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV. Name of Plumber: MP/MPRSW No County: Samtary Permn Number: Bytcvn BiAd It. 3318 St. Ct oix 112761 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIOUID CAPACITY: TANK INLET ELEV.'. TANK OUTLET ELEV.. WARNING LAB L LOCKING COVER '1 pp PROVIDED: PROVIDED �l bliLl / O 4�,�5 q(��03 54YES ONO ❑YES &NO BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD, PROPERTY WELL'. BUILDING. VENT TO FRESH ALARM FEET FROM LIN ' „ w AIR IN�Et DYES O II C1 ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY:]=MPISIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: OYES ONO DYES ❑NO [—]YES ONO PUMP AND CONTROLS OPERATIONAL. NUMBE OF PERTV WELL BUILDING V GALLONS PER CYCLE: E AIR INLET (DIFFERENCE BETWEEN FEET F PUMP ON AND OFF) DYES ❑NO NEARE T SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH D TER 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 aPITS LIQUID BED/TRENCH TRENCHES + TERIAL: PIT DEPTT+ DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR PI F DISTR.PIPE DISTR.PIPE MATERIAL. NO D R. NUMBER OF PROPERTY RTV WELL BUILDING VENT TO FNESV+ BELOW PI ES AB,VE COVER EV IdNLET ELEV.ENO. PIPF FEET FROM LINE - I I I W I A��ET ..+. r• � 1 0,/IZ5 C � of NEAREST JT 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 ELEVAtiy meets the criteria for medium sand. TIONS MEASURED. DYES 1:1 NO SOIL COVER TEXTURE P MARKERS OHSEH NATION WELLS DYES ❑NO DY ES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH of TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES. DYES ENO DY ES ONO OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES. LATERAL DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE IMAN1101-7DIMATERIAL NO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.'. ELEV.'. DIA. ELE V.. DIA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING'. DRILLED CORRECTLY ERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO 1:1 YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WE L LS. NUMBER OF PROPERTY WELL'. BUILDING. FEET FROM LINE: ❑YES ❑NO DYES ❑NO INEAREST--� Sketch System on Retain in county file for audit. Reverse Side. g URE. TITLE Zoning A&nind 6 tAatvtc � DILHR SBD 6710 IR.01/82) =1jL SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# //9yt'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 (�7 f. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES I/N NO PROPERTY OWNER PROPERTY LOCATION ,eQ '/< �'/a, S T , N, R t E(or PROPERTY OWNER'S MAILING ADDRESS LL OT NUMBER BLOCK NUMBE SUBDIVISION NAME 7 .70/n C -.� CI Y,STATE ZIP CODE PHONE NUMBER En CITY N ST ROA KE OR LANDMARK ! VILLAGE. : 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. El 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. neepage Bed b. ❑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): � L 3 11/� 6sZ Feet J farrivate ❑Joint ❑ Public VI. TANK CAPACITY 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 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 ame(Print): Plumber's S' ature:(No Stamps) MP/MPRSW No.: Business Phone Number: s r ." Plumb s A "(Street,City,State,Zip Code): Name of Designer_ O �P/ riF/J� 07i J t I" Vlll. SOIL TEST INFORMATION Certified Soi Tester(CST)Name CST# a^t ./ , a CST's KID ESS(Street,City,State,Zip ode) Phone Number: IX. COUNTY/ EPARTMENT USE ONLY �.�t F-1 Disapproved Sanitary Permit Fee Groundwater ate Is 'ng�igna�(No Stamps) D(lApproved ❑ Owner Given Initial S, charge Fee Adverse Determination X. CPMMENTS/FOASONS FOR DISAPPROVAL: lilac, rYk� 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; �. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 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; r. If you have questions concerning your privat_ sewage syste,-,, contact your local coda administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit :application must include: Property owners narne and mailing address. Provide the legal description where the system is to be installed; !'. Type of building or use served- K 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; IH. 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 81/2 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 Wiscorisin' can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that. buried reasur a 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. a 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 v-ate-, groundwater contamination investigations and establishment of standards. Groundwater, is worth protecting. Sc3D-6398(R.03/86) r 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 44!: 4: �� 4 h'-LE,x) J job -Z>4Vi A Location of property /V_--'�-Zl/4 A)(5-1/4, Section T N-R W Township Mailing address 46- --L— Address of site .S' ✓� C=- Subdivision name e-rs /'h [/ 4C-�d-n-�C�r'(�- �1-3(o F7-3 Lot number Previous owner of property 7/4-q Wes cc Total size of parcel aC-r-e� • Date parcel was created i')74i-" Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house)? Yes No Volume 2/!5' and Page Number os 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. Q 59 /3-1 ; and that I (We) presently own the proposed site for the sewage disposal system (or 1 (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 t e County Register of Deeds, as Document No. Sig ature of Owner Signature of Co-Owner (If Applicable) Date Signature Date of Signature 5 3 DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA ii STATE 'BAR OF WISCONSIN FORM 2-1982 II 43913 ; REGISTER'S OFFICE ST. CROIX CO., WI .......................................................................... ............................ ......... Rec'd for Record 1i ................................ an .............................. .................. .................. .............................................. JUL 5 1988 li .................................................................................. ...... conveys and warrants to Leanne A. Klein and Davi R. at 1:00 PM ....................0... ................................. ...........0..................................................................................................... ............................................. ................ .................................................. Register of Deeds I. ............................................................ .................................................. .....................................................................................0..................... ................................................................................................................. RETURN TO Century 21 ................................................................................................................. Somerset, W1. ......................... .......................•-----•-----.....------ ...........0...........................=.............................................. the following described real estate in ......St Croix ....................0.....................County, State of Wisconsin: Lot 1 of Certified Survey map filed Tax Parcel No: ........................ in the St Croix County Register of Deeds Office. May 4, 1988 as Document #436973 in Vol. 7, page 1961; Which is Part of the NJ of the NEI of Section 11, ii Township 31 North, Range 19 West, Town of Somerset.- St. Croix County, Wisconsin ii PRANSF $ FEE Fj �J ii it This ..............is.............. homestead property. (is) (is not) Exception to warranties: recorded easements and rights-of-way. 88 June 28 th Dated this ................................................ day of 19......... ................(SEAL) ......... ... . ....... ........... .................. .............. ..........(SEAL) ........................................ .............. .................................................... .............:.....•---•-•-••---._.0..._....._------------------ ..........(SEAL) ................................ (SEAL) ...... .... .............................. ...................0........ ........ ......... .......... ... .................................................. Ac $kes C. Cook AUTHENTICATION ACgNOWLEDGMENT STATE OF WISCONSIN Signature(s) ------------------------------------------------------------ St Croix -------------------------------------------------------------------------------- .................. ...................County. Personally came before me th ..28th authenticated this --------day of..........................119...... June is --------- I 19P.�--- the above named --------------o------------------------------------------7------------- ........... ..............................0....... .............. . ...•.............................••....••... ------0......................................................................... ............... .... TITLE: MEMBER STATE BAR OF WISCONSIN ................................................................................ (If not. --•--------------------------------------•------...------•-- •-----•---•-------......------..--..-•-•--•. ••---•--........_............. ................................0.............................................. authorized by § 706.06, Wis. Stats.) to me known to be the person ............ who e ecu ed the foregoing *nstru ent and acknowledge the I e. THIS INSTRUMENT WAS DRAFTED BY c Ij1 ......... . . .... ...... ....4....... % ...................... John ............................. 0A .. ....... .. . ....... ... ........ .... ........... a D. Wa 1 .................-- ----•-------0----------------- ig6a S t 11 ----- Notary Public ....................IN--------- • My Commission is perm��4.(If A0 -Aw I P.�pvtr',�it In. 5 may be authenticated or acknowledged. Both Dec. 1P sary.) date: ................................r*.............o-k... 19—... L I Ing In any capacity should be typed or printed below their signatures. A 4. STATE BAR OF WISCONSIN wisco C.'. I fie. FORM No. 2— IV82 "I i 1'.INV*I STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L�1� �rl�/� . �� / / �,� t�l i2,. +L.6 e`PKC ROUTE/BOX NUMBER FIRE NO. CITY/STATE,SoN'6i—=;/LTj -F—, ZIP S y0 �;)_� PROPERTY LOCATION:9 I'V 1/4, Section / l , T�N, R d W, Town of 5o -14 7 , St. Croix County, Subdivision S Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents 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 roi County Zoning Office within 30 days of the three year expiration date. SIGNED DATE a 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& BUDIVISION ILDINGS DUSTF�Y, _ �- - - -- - LBOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: SHI MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: �/ ,nom,./Ty COU 19TY: ER'S/BUYER'S NAME: MAILING ADDRESS: r77. Gr n a �ei` USE DATES OBSERVATIONS MADE INO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ER OLATION TESTS: Residence ❑New g Replace /I '1� —,,q RATING:S=Site suitable for system U=Site unsuitable for system rn,�,O ENTIOaNAL: MOUND:❑� IN-GROUND SYSTEM-IN-Fl TANK: RECOMMENDED�YSTEM:(option I) SS UU S LrQ�J+ UU S UU SS I(M JN� (.� J. If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- Q w o ©- � � � o?o— yo� B eZ 9� 020 67,000'e..7 B- B- B- PERCOLATION TESTS C TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PER1007 PERIOD2 PERIOD PER INCH P- R dt G P_ O� 3 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 B GS ®WC// - `4 _ - D ®T TN O 2 sXy My 6o f . 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: E CERTIFICATION UMBER: PHONE NUMBER(optional): CST SIGN UR : a- al Authority,Property Owner and Soil Tester. —OVER — A 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 resi(jence or commercial project; 1 MAXIMUM number of bedrooms tar•commercial use planned; 4, is this a new o€ replacement system; a_ Completes the suitability rating boxes,A SITE IS SUITABLE FOR A HOLDING TANK ONLY 'F ALL. OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE use the abbreviations shown here for writing profile descriptions arid completing the plot plan; 7. MADE A LEGIBLE diagram accurately locating your test locations. Drawing to scab: is preferred. A separate sheet may be used if desired; €3. 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:exernp- tion, if appropriate; 10, If the information (suet) as flood plain,elevation)does riot apply, place N.A.it) the appropriate box; 11. Sign the form and plane your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED VVITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Snail Separates and Textures Other Symbols st - Stone ;saver 10") BR Bedrock cot) - Cobble (3- 10") SS - Sandstone qr --- Gravel (under 3") LS - Limestone s Sand HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate Hied s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is - Loamy Sand > .. Greater Than "sl - Sandy Loam < - Less Than 'I - Loam Bn - Brown sil Silt Loam BI -... Black si - Silt Gy - Gray cl -- Clay Loam Y ...-. Yellow scl _. Sandy Clay Loan) R - Red sir.) Silty Clay Loan) mot Mottles sc Sandy Clay w/" - with . sic - Silty Clay fff -..... few, fine,faint c Clay cc - common, coarse pt - Peat mm - Many, medium m - Muck d - distinct p - prominent HWL - High water level, - - Six general soil textures Surface water for liquid waste disposal BM Bench Mark VRP - Vertical Reference: Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. PLOT PLAN 2R J ,CT _ADDRES ��m�r5� l; W1/4 1/4/S/'//T,V N/R/ W TOWN OUNTY roi MPRS Byron Bird Jr. 3318 DATE — BEDROOM CLASS PERC_„/CONVENTIONAL-GROUND PKfSSI IRE CONVENTIONAL LIFT_MOUND_HOLDI G TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA --� PERC RATE BED SIZE 16 Benchmark V.R.P. Assume ElevatioaJ00' Location of Benchmark �Y22'a * H.R.P. �J E3 Borehole Well Scale = Feet vim,� O Perc Hole System Elevation $ . TYPAR COVERING 2' 12• 3- 4 6' Q 3- I 1 Sewer Rock 12' L I P II r_ p D— r 5411" X33 i I a�