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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP Sn r._e r re T SEC. T -'?O N-R/9W
ADDRESS 20� L a ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
i
�Aistances and dimensions to meet requirements of I•IHR 83
II SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Q�
v �
)t
66�Tb Sq ri
oe
Qe
(�7 <1
10005 c
E 5e0 t✓� r
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: 1 '`' Proposed slope at site:
SEPTIC TANK: Manufacturer: Ljj'ej-,er1 Liquid Capacity: /0 d 0
Number of rings used: �, Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side 10Rear, Q // 6 -feet
From nearest property line Front 10 Side 10 Rear, feet
Number of feet from: well building: „7/
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
.SEE RES MILE
r
PUMP CHAMBER /V/
fi .
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: /Z� Length: 1 Number of Lines:_tea„ _ Area Built: 6 3 (e
Fill depth to top of pipe:
Number of feet from nearest property line: Front, 'Side, O Rear, Ft .___1__
Number of feet from well: 7
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT v/
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 H111-1
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:
moo- a 0 1,�.:�...
Dated: S Plumber on job:
License Number:
3/84:mj
CIEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
ON
I
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVISING
P.O.BOX 7969
MADISON,WI 53707
SE%,SE4,S12,T30N—R19W rICONVENTIONAL ❑ALTERNATIVE Ser
(If assigned)
Town of Somerset ❑Holding Tank ❑In-Ground Pressure ❑Mound
85th Street
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: ,
Richard Flandrick lRoute 4, Box 218, New Richmond, WI 540 7 -00���
BENCH MARK(Permanent reference pm 0 DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: JCSTREF.PT.ELEV..
Name of Plumber MP/MPRSW No.: Co mfv'. Sanitary Permit Number
Michael E. Wilson I6388 St. Croix 106113
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY'. TANK INLET ELEV.'. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
] p PR VIOED PROVIDED �,/
W r ( 01,7.0 ,7 / ES ONO DYES %0
BEDDING: VENT DI A.. VENT MATL. HIGH WATER NUMB R F ROAD: !ERTY WELL'. BUILDING.1 VENT TO FRESH
ALARM / IAIR INLET
❑YES NO < ED YES ONO NEAREST M /( � �
DOSING CHAMBER:
MANUFACTURER BEDDING'. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNOVIING LABEL LOCKI
PROVING COVER
PRDED: DED:
❑YES ONO ❑YES ❑NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERAT IONAL'. NUMBH OPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN E AIR wLEr
FEET FPUMP ON AND OFF) ❑YES ❑NO NEARESOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH TER IVATERIAL 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 CIA -PITS LIQUID
BED/TRENCH TRENCHES NtA RIAL' PIT DEPT"
DIMENSIONS 2
GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI NUMBER OF PROPERTY WELL BUILDING V NT TO FRES/1
BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END'. PIPES FEET FROM LINE / /J AIR IpI,L �
G L S G" C ,�q L� 2 7 NEAREST V, 5
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.
DYES ❑NO
SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS
OYES ❑NO ❑YES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =PSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES El NO OYES 11 NO ❑YES El NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERAL SPACING JGRAVIL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR [STR.PIPE DISTHIBUTION PIPE MATERIAL.&MARKING
ELEV. ELEV,. CIA.. ELEV.. PIPES A..
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLAN$CAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO - DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL'. BUILDING:
FEET FROM LINE.
3 ❑YES ❑NO [:]YES ❑NO N EAR
EST—�
a .40
Sketch System on �— "- ,Re,tain in county file for audit.
Reverse Side.
SIGNATUR TITLE
Zoning Administrator
DI LHR SBD 6710(R.01/82)
:,(�Er DILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code L
STATE SANITARY PERMIT#
/ 6 /12
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8'h 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
l ' /C E '/a S C '/a, S T_3 v , N, R / E (or)
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
R '00x -air — — ,--
CITY,STATE ZIP CODE PHONE NUMBER 77 CITY NEAREST ,LAKE OR LANDMARK
i hJ �, i(o F-1 VILLAGE : g,SST
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 41— OR ❑ Public(Specify):
111. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. KNew 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. KConventional 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. M.See a e Bed b. ❑See a e Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): C
30 SZ3 7 S"� / Feet XPrivate ❑Joint ❑ Public
CAPACITY
VI. TANK ##of Prefab. Site Fiber- Exper.
in allons Total Manufacturer's Name Con- Steel Plastic
INFORMATION New xisting Gallons Tanks Concrete glass App.
Tanks Tanks Q'77 structed
Septic Tank or Holding Tank /4 f` L-1 i C J- n ❑ I I ❑
Lift Pump Tank/Siphon Chamber ❑
VII. RESPONSIBILITY STATEMENT
1,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) /MPRSW No.: Business Phone Number:
/",'c,4 r. -(- C- C-xa,. �--- Z� 4-71Z.— 6--3 kP, 71 Plumber's Address(Street,City,State,Zip Code): Name of Designer:
k l" C,.!` o0
Vlll. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST##
a a,- A y
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
/t' q a d x r YO 7/S- a26J-- 76 /
IX. COUNTY/DEPARTMENT US ONLY
j ❑ Disapproved S @initary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
�J Approved ❑ Owner Given Initial S r71, Surcharge Fee q C
Determination �
Adverse
X. CO ENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be'properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
G. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-2.66-3815.
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;
!I. 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;
M. 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 I
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground ata�--
i; ,luded the creation of surcharges (fees) for a number of regulated practices which V1'iscorn
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buriedreasure
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper. �L
-:ion es :olio ctec: through these surcharges a-e c-edited to the groundwater Bird adrrinis-
i=rep by tl e `_)epartment of Natural R �source�. These funds are used for monitoring ground- t
atw, gr cur:-iwater contamination in=estigations and establishment of standards. Ground vate.r,
s v,orth protecting.
ti 3D-6398(h.03B6)
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 _ � 2 __ c ,
Location of property _1/� 1/4, Section T_,16_N-R LW
Township
Mailing address
7
a
Address of site
Subdivision name.
Lot number
Previous owner of property 9
Total size of parcel 01CI& L_
Date parcel was created y
Are all corners and lot lines identifiable? P Yes No
Is this property being developed fo r ele (spec house)? Yes e� No
a
Volume and Page Number as recorded with the Register of Deeds.
----------� _ �. �_ _ ______r�I�___________________
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 rernrded in the Office of
the County Register of Deeds as Document No. u _ _ ; and that I (We)
presently own the proposed site for a 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 dul recor ed in the Office
P11'e
t hA Couy4y Regis f D ds, s Qocument No. ) .
f
ignature of wner Signature of Co-Owner (If Applicable)
Date f Signature Date of Signature
_.._..........
j 'DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
,,�34 �t' Ida n REGISTER'S OFFICE
�"� �w^ ,�----- _ ST. CROIX CO., WI
- ---------------._.-_._.___ - -- -------�---- Recd x,:,; Record
Feb. 9, 1988
.- Richard..Flandri.ak...and..Cy-rely.a...Flaildrzi.ck.,..............
e......--•................................•. 11:20 A M
•------------------•--.............................----•-----•---.............-•---•-••-••••••--•--••........-•-•
.. .. -- • --•- ------------ •• ...........................................
conveys. and warrants to ..Richard...A.-...Flaridrick...................: Register of Deeds �0
.....................-............_._........
-------------------•---•-•--.----------•---•----------.--.-.-.---..---•------.-----..------•---------••-•----•---
................................................................................................................. RETURN TO
......... ................................_......._......................................._...._....
the following described real estate in ......S A...CXQ.IX....................County,
State of Wisconsin:
Tax Parcel No: ..............................
Part of the West Half of the Southeast Quarter (W'h of SE'h) , Section
Twelve (12) , Township Thirty (30) North, Range Nineteen (19) West,
i described as follows: Lot One (1) of Certified Survey Map filed
February 4, 1988, in Volume " 7" of Certified Survey Maps, page
1937, as Document No. 434238.
i
I
This ....1.-5..AQt......... homestead property.
(is) (is not)
Exception to warranties:
14-
Dated this ........................ ................. day of .... ebruary. ......., 198.8....
1
0 1 ,
I
�1
----------(SEAL) �t-�d -�cf ...........(SEAL)
Ri.charr d..Flandriilc......................... ' __-Cyr-ella--- 1-andri-ck----------------------
i
----•-----•-......•---••........•.(SEAL) ...................•--•-----------...--•---•........._...__...._.._.(SEAL)
ii
'I I
li
AUTHENTICATION ACKNOWLEDGMENT
it
li Signature(s) _ .f..Richaxd__-Flandrick.......... STATE OF WISCONSIN it
• ss.
I� alld Cy .la._ i dry (;k.---------•................
(i r y ....................................County.
auth ti s ., .day of...Flabr.14aln ..—, 19-8.8. Personally came before me this ................day of
..........................................1 19........ the above named
Ii •..... of _1?-...Needham`:
TITL • M MBER STATE BAR OF WISCONSIN
---{ °tmt;------------- .................. ......--------------------------.........-------------•---•-----•---•-•.........
to me known to be the person ............ who executed the
foregoing instrument and acknowledge the same. i
j THIS INSTRUMENT WAS DRAFTED BY
Reinstra, Van Dyk & Needham, S.C.
...................................... ............................................ ................................ i)
Nevs•.Riehmand,-..Fiia�oxl .�.??..._. 4 Q1�--012 7 Notary Public ..........................................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.)
date- ......................................................... 19.........) II
•Names of persons signing in any capacity should be typed or printed below their signatures.
H.GMiIlerCompsly� — -_-- STATE AM O WISCONSIN _--'-----�-- - —StOCI( NO. 13002
r.........wrs«w
• I
ST . CROIX COUNTY CERTIFIED SURVEY MAP NO .
RECORDED IN VOLUME OF CERTIFIED SURVEY MAPS
ON PAGE -- . LOCATED IN THE WEST HALF OF THE
SOUTHEAST QUARTER OF SECTION TWELVE, TOWNSHIP MAP BEARINGS ARE
THIRTY NORTH, RANGE NINETEEN WEST, TOWN OF REFERENCED TO THE
SOMERSET (SOUTH PART), ST. CROIX COUNTY-, NORTH / SOUTH i
WISCONSIN. LINE OF SECTION 12
T-30-N, R-19-W.
PREPARED FORt Rick Flandrick ASSUgEDDOo "-ETO BEAR
R.R. 4. Box 218, N OQNOATHj00 .
New Richmond, Wi. 54017 tt
PREPARED BY t Lee Villeneuve, R.L.S.
R.R. 6, Boa 150, Menomonie, Wt- 54751
z NORTH j CORNER OF SECTION 12, SCALE IN FEET — I"=100'
T-30-N, R-19-W
NORTH - SOUTH LINE OF SECTION 12 10b' 60' 100'
= r L3GEN. .D
a V P.O.B. POINT OF BEGIN-
0 W
z ;UNPLATT3D LAND NINE.
J ( ffi ST. CROIX COUNTY
MONUMENT POUND.
EA5 r 282.52 O 1" X 240, IRON
2 9.5 PIPE WEIGHING
33' 33' «, lo-1 POUNDS PIER
�. �
LINEAL 28 �.ON
" w
k 1-15 r,418 SQUARE .FE t L PIPE WEIGHING
4 ( 2.65 ACRES) EXCLUDING 1 .70 POUNDS PER
ROAD RIGHT OF WAY LINEAL FOOT SET.
Q LOT ,
h � h
N
'130,682 SQUARE FEET top ' L
( 3.00 ACRES) INCLUDING io Z�
}t ROAD RIGHT OF WAY
Z
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"282.52
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SEPTIC TANK MAINTENANCE AGREEMENT H
St . Croix County
d '
OWNER/BUYER i' G •a-y- el !� ..��,ox.�.,��.�c-c�Ge� _ rX3
ROUTE/BOX NUMBER 44 a /$ Fire Number
CITY/STATE W.� ZIP ,r_q6 / "-7
P�
PROPERTY LOCATION : ,,J %, S � 4i Section . l , T 30 N , R / q W ,
'town of St . Croix County ,
Subdivision Lot number_.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists of pumping out the septic tank every three years 'or sooner ,
if needed , by a licensed septic tank pumper . What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system .
St . Croix County residents m_� be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978 . St . Croix County
accepted this program in August of 1980 , with the requirement that
owners of all new systems agree to keep their systems properly
maintained .
The property owner agrees to submit to 'St . Croix County Zoning a
certification form, signed by the owner and by a master plumber ,
journeyman plumber , restricted plumber or a licensed pumper veri-
fying that (1 ) the on-site wastewater disposal system is in proper
operating condition and (2 ) after inspection and pumping ( if nec-
essary) , the septic 'tank is less than 1/ 3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration . ti
C
I/WE , the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth , herein , as set by the Wisconsin Depart- v
meat of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning
g Offie with' 30 days
of the three year expiration date .
IS IGNED AJA i A�
DATL
St . Croix County Zoning Office
P . O . ;3ox 9E'
fiammoGid , WI' 54015
715-796-2239 or 715-425-8363
Sign , date and return to above address .
UENAHIMENTOF
ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR RELATIONS PERCOLATION TESTS (115) P.O. BOX 3707
HUMAN RELATIONS 1 / MADISON,WI 53707
(ILHR 83.09(1) &Chapter 145)
ELQCATIQN: SECTIONNSHIP N�1 ICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:%45� V4 r /T,(.)N/R� E(or W �fl�TY: OWNER'S BUYER'S NAME: MAILING ADDRES
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMM R IAL DESCRIPTION: PROFILE NS: PERCOLATION TESTS:
AResidence �r XNew ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system
LAJ ONVENTI,AL: MOUND: IN-GROUNDPRES§URE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
S DU S ❑U S DU DS U MS RU
If Percolation Tests are NOT required DESIG� AT If an
y portion of the tested area is in the
under s. ILHR 83.0915)(b),indicate: L3 f Floodplain, indicate Floodplain elevation:
Z - _PRO ILE DESCRIPTIONS
BORING TOTAL PT O GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B-3 J� -� �1 c j D / '�''`� �d ✓n -ltd- j� �,?�
B-
f-«� PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 RI D PER INCH
P-
P-
P- i
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
V\o
_M_
O
O O,
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:
o�, l ( e6 — q.
ADDRESS: (CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST SI ATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. '
DILHR-SBD-6395(R. 10/83) —OVER —
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