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Parcel #: 038-1164-40-000 01/12/2006 04:24 PM
PAGE 1 OF 1
Alt. Parcel#: 30.31.18.778 038-TOWN OF STAR PRAIRIE
Current X'' ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
THOMAS W MARTELL O-MARTELL,THOMAS W
439 208TH AVE
SOMERSET WI 54025
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description * 1909 RIVER VIEW LN
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 1.535 Plat: 0227-CRESTVIEW ADD
SEC 30 T31 R1 8W LOT 14 OF CRESTVIEW Block/Condo Bldg: LOT 14
ADD.
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-31 N-1 8W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 827/537
07/23/1997 748/169
07/23/1997 704/38
07/23/1997 666/186
2005 SUMMARY Bill M Fair Market Value: Assessed with:
120019 238,100
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.535 28,800 205,200 234,000 NO
Totals for 2005:
General Property 1.535 28,800 205,200 234,000
Woodland 0.000 0 0
Totals for 2004:
General Property 1.535 28,800 205,200 234,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER L1ry1� ��4 TOWNSHIP Shoe y6zzj,E' SEC. T ,fZ_N-R Zt? W
ADDRESS 1\ ST. CROIX COUNTY, WISCONSIN
Sa�.�sie� U'V L C l�li�l1
SUBDIVISION f��,�cr,J LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/.�
3s
01
IVK. af�c.r9lf use,o �- .
r4,K /; /Xf k�- ?�'b'� 10,7,o/
a /Vit, e /`C�!.P ^/,��'"/`
17 11 'l l Ai S 0,c -- INDICATE NORTH ARROW
�/. 116+ `l -
BENCHMARK: Describe the vertical reference point used 4,114
Elevation of vertical reference point: Proposed slope at site:
N.
SEPTIC TANK: acturer .�rCs L'i.&&425g itg�iquid Capacity:
Number of rings used: Tank manhole cover elevation: _.'��, �
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from'neargIr Road: /
Front,O Side Rear,
From nearest property line Front,OSide,�Rear,O,
Number of feet from: well -�� � building: .
(Include this information of the above plot plan)( 2 'reference
L S'
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
,.Width: _ Length: Number of Lines: Area Built
y
Fill depth to top of pipe: Q
Number of feet from nearest property line: Front,/,=Q Side, O Rear,O Ft . ^
Number of feet from well:
47 0
Number of feet from building: le
(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:
Inspector:
Dated: Plumber on job: �.�
License Number: Z
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
P..Ak.00*-7—A69
MADISON,WI 53707
SW 4,SE%,S30,T31N—R1$W CONVENTIONAL El ALTERNATIVE S
Town of Star prairie El Holding Tank ❑In Ground Pressure El Mound
Lot 14 Crestview Addition
NAME OF PERMIT HOLDER'. JADDRESS OF PERMIT HOLDER: INRSPECTION DATE
Tom Martell Rural Route Somerse WI 54025 1912��g$
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.
Name of Plumber MP/MPRSW No.'. County: Sanitary P,—t Number:
Calvin Powers Jr. 1563 St. Croix 106117
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. UID CAPACITY. TANK INLET ELEV.. TANK OUTLET E LEV. ROVIDEOLABEL PROVIDED OVER
DYES ENO ❑YES ❑NO
BEDDING. VENT DIA.. VENT MATLEjE R ROAD: PROPERTY WELL. BUILDING VENTTOFRESH
NUMBER OF LINE JAIR INLET
FEET FROM
DYES ❑NO ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING.
ILIQUIDCAPACI TY PUMP MODEL. PUMP/SIPHON MANUF ACTIIRER gOVIIDEDLABEL PROVIDED OV ER
OYES FIND ❑YES ONO ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
LINE AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) DYES NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
FORCE
or excavation. (If soil can be rolled into a wire,construction shall cease until
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH. LENGTH NO.OF DISTR.PIPE SPACING COVER INSIDE DIA �PIiS LIQUID
BED/TRENCH TRENCHES. MATERIAU PIT DEPTH
DIMENSIONS
GRAVEL DE P7H FILL DEPTH DISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL'. NO DISTR NUMBER OF PROPERTY WELL BUILDING VENT TOF FRESH
BELOW PIPES. ABOVE COVER ELEV INLET ELEV.END. PIPES LINE AIR INLET
FEET FROM
NEAREST
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 ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES 1:1 NO PER MANEN T M A R K ER, O BSI H V A T I O N IIW L LS
SOIL COVER TEXTURE
❑YES ❑NO YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDE�.�� 0 DYES MULCHED
CENTER EDGES
❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH'. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MA TERIAL&M1IAHKIN(�
ELEV.'. ELEV.. DIA.. ELEV. PIPES DIA
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL
PLANS
I ___]
❑YES ❑NO DYES ONO
COMMENTS: ' PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF LRNE ERTV WELL: / BUILDING
FEET FROM �/�f/
❑YES NO DYES ONO NEAREST
0
sr
.-JON- '
Retain in county file r audit.
SIGNATURE. TIT
Zoning Administrator
NEW
I
SANITARY PERMIT APPLICATION 7-1/y-,� OiLHR In accord with ILHR 83.05,Wis.Adm.Code ��Q'
STATE SANITARY PERMIT#
/O 7
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8'Y2 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
PROP TY OWNER'S MAILING ADDRESS LOT NUM R BLOCK UMBER SUBDIVISION NAME
- fF
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, KE OR LANDMARK
1HTOWNOF
VILLAGE
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): �(f�
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. X 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. ❑seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minu es 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 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 ❑ 1 ❑ 1 ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber' Name(P ' t): I P ber's Signature (N Stamps) MP/MPRSW NO.: Business Phone Number:
[pFumb is Address(Stree,Ci y,Stat ip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Cert''ed S iii Tester ST)Name CST#
CST's AD R S ( treet,City tate, ip Code) Phone Number:
IX. OUNTY/DEPA TMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
IR 4{!�3
Approved ❑ Owner Given Initial Surcharge Fee
($�6b //�p /`�L✓
Adverse Determination LLJ� O
X. COMMENTS/REASONS FOR DISAPPROVAL:
J"
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
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
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;
Ill. 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 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 At@F
included the creation of surcharges (fees) for a number of regulated practices which Wisco EkI"S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r+easre ' a
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
STC - 100
his application form is to be completed in full and signed by the owner(s) of the
roperty being developed. Any inadequacies will only result in delays of the permit
esuance. Should this development be intended for resale by owner/contractor, ("spec
ouse"), then a second form should be retained and completed when the property is
old and submitted to this office with the appropriate deed recording.
er of Property
Location of Property S11) k �1%, Section _ ,�� , T �-N-R Zff W
Township ,ten
Mailing Address 7�
AV 14
Address of Si
Subdivision flame
Lot !dumber f
r _
Previous Amer of Prope ty
Total Size of Parcel? 3 CL^- ,--_
Date Parcel was Created 1z
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for resale (spec house) ? Yes X_11�_ No
Volume and Page Number ,�1 as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A warranty Deed which includes a Document number, volume and oaRe 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
i (We) cv.W6y that aCt statements on tI ' ohm aAe, .tAue to .the bust o6 my (ouA)
hnmtedge; that I (we) am (aAe) the own eAk o6 the phopehty de�scA.i.bed in thiA
Lt f
i"Wma. on 6o4m, by vdh-tue o6 a waAAanty deed AecoAded in the 066ice o6 the
Corin.ty RegihteA o Deed�sah Document No. ; and that I (We) pRe.aenLty
CRUM pptopod c to bon the sewage digs ors d b em (oA I
p y (we) have obtained an
ensPJ++t►tt, h wt,th .tile above d6chibed phopeAty, 6oh the eonAtAucUon o6 eaid
ayatun d een duty k cohded Xn the 066ice o6 the County RegiAteA o6
Vet ,
SI ATURfI or OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
SInlo y ;yk
DATE SIGNED DATE SLED
.*bai'y ppGUM(=.��-�- Nom. " ! THIS SPACE RESERVED FOR RECORDING DATA ,
WARRANTY DEED
f!
li STATE BAR OF WISCONSIN FORM 2-1982:1
Boy 48'ME I:�� RMS?ER5 OFFICE
j ST. CROIX CO., W IS.
- -- Les.ter.-H••.-.11antell_ . ----- --- ------ ROC�e�. fir Record this 25th
- _ - - --. _. _ .. _ .. _ . -_.. . . ------- - -
�( July A.D. 19 86
I ---------------------------..- - -- -._ .-------- --- _-- y of
conveys and warrants to _ ..Thomas W. -and Marjorie A. Martell,
husb_and-_and_wi£e-_as..Joint.__tonants------------------ ----- ? w ♦,
--._ . . . --- -- - - -- . . - . --
I ---- ---- -- ------ --------- ----- -----.._ -----
.
.. .. -.. -_-_ ----------------- ------------------. ... .. ..... ... R TO ..__.-. :.._....
_ ._._ ETU RN
---
- .- .. -. _ _ -------- . ._ i
#I the following described real estate in St
Croix County,
State of Wisconsin:
Tax Parcel No- ------------- -------------
Lot Fourteen (14) , Crestview Addition located in SW1-4 of SE14, the NW114 of the l�
SE4 and the NE14 of SE of Section Thirty (30), Township Thirty-one (31) North, .I
Range Eighteen (18) West. This deed is in satisfaction of a land contract
. 19
dated
kj
ii
� h_fmn `
I
}+
j This _ is_.not_-_ homestead property. 1
(is) (is not)
:I
Exception to warranties: '
Easements of record.
�I
Dated this --- --16-th -- ------- ------ ---- day of ------ July-- -- ----- 19- 86
! .(SEAL) .' ///4Q- ------(SEAL)
-" * ---Laster H.. Max.tell_ -. __.... . -----
--------
(SEAL) ---- - -- ---------- ---(SEAL)
-- ---- - - jf
AUTHENTICATION ACKNOWLEDGMENT
Signatures) -------------------------------------------
------ --------- STATE OF WIBCONSII*F
ss.
------------------------------------------------------------------ St Croix
County.
of
authenticated this ___.._day of__ .._.__ .-________-, 19.-_.. Personally came before me this ._._.ltli_--day
G
H
a
• r
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
OWNER/BUYER � --/�. ��-�// M
ROUTE/BOX NUMBER j� Fire Number
CITY/STATE.(�ANh24"f-C/ � ZIP
PROPERTY LOCATION: _-jpt) 'k, :5 ,6 _ , Section_, T -31 _N , R /2_W,
Town of %%
Q ,P /�(!a�> St . Croix County ,
Subdivision � Z 6)1W11J Lot number'
I
Improper use and maintenance of your septic system could result in i
its premature failure to handle wastes . Proper maintenance con- I
sists of pumping out the septic tank every three years or sooner , I
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 may 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 . H
0
E
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accord nce with H
the standards set forth , herein , as set by the Wisco i De art- v
ment of Natural Resources . Certification form m comple d
and returned to the St . Croix County Zoni hin 30 ays
of the three year expiration date .
SIGNED .�• ,y/,q,�/ p�/
DATE
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
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1)&Chapter 145.045)
LOCATION / SECTION:� :N/ �� TOWNSHIP/MU IPALITY: LO;NO:BLK. . SUBDIVISION NAME:
(or
COUNTY OWNER'S/BUYER'S NAME: MAI ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BED 1COMMERUI L DESCRIPTION: �PROFI E DESCRIPTIONS: ER DILATION TESTS:
I.xResidence XNew dy
RATING:S=Site suitable for system U=Site unsuitable for system Q�-
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
ms ❑u s ❑u s au a s ®u 0S ®u
If Percolation Tests are NOT require DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: 11i
PROFILE DESCRIPTIONS
BORINGI TOTAL D PTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEX RE,AND DEPTH
NUMBER IDEPTH 11®. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF 9L3SERVED(SEE ABBRV.QN BACK.)
nl ljgW4 ' nJ Qodf — "V S .d .4,yA069 C s
RIO AAS-
B- 7 -I
B- 911,17 d
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER D1 PTH AFTERSWELLING INTERVAL-MIN. PERIO t PERIOD.2 PERIO 3 PER PER INCH
P / `/
I
P_ d7
P-
so
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 po/intg a�d sho5Peir location o the plot plan. Show the surface elevation at all borings and the direction and p rcent
of land slope. a/���`a 4 �Awi L— e S� 8ry Ap
SYSTEM ELEVATION ,fe
I 4
p
3
-4 - TN
F-ir I
E
¢ I
i t I ,
i qq
/ e � �
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 Wij nsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAM prn TESTS WERE COMPLETED ON:
se
A R CERTIFICATION NUMBER: PHONE NUMBER(optional):
AW
C G ATUR
i
i
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
— .. —
~
INSTRUCTIONS FOR COMPLETING FORM 1?5 - SBD 6385
To b°udomp|*temnd accurate soil test,ynu, report Most indude:
7� Complete legal description;
2. The use section mmgdeady indicate whmhwrthio is residence orcommercial project:
3, MAXIMUM number of bedrooms or commercial use planned;
4, |s this o new nr replacement system;
5. Complete the suitability rating boxes, ASITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED g0 SOIL CONDITIONS;
S� PLEASE use the abbreviations shown here for writing Profile descriptions and completing the plot plan;
7, MAKE A LEGIBLE diagram aorusm|y locating your test locations. Drawing to mm|e is preferred, A
ouporacrshee1 may be used if desired;
S. Make sure,your benchmark and vertical e|oxm1\on reference point are clearly shown,and are, permanent;
9� Cumn|ete all mpvrup,iom boxes as to dates, nameo'addressoo' flood plain dota, percolation test exemp-
tion, ifapp,oprime�
YD. |f the information (such as ',food plain,elevation)doosnc«apply, place 0,/\� inthampprnpriatobox;
11, Si8n the form and place your uu/len address and you, certification number;
12� 'Make legible nopiao and distribmv as required, ALL SOIL TESTS MUST BE BLED WITH THE
LOCAL AUTHORITY VV/TH|N3O DAYS OFCOMPLETION,
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and TvxtorOS Other Symbols
x| — Stone (Over 10") BR — Bedrock
col) — Cobb!* <3 lO^> SD — Sandstone
Q, — Gnxme| (under 3") LS — Limeotono
=o — sand HQVV — High 6roundvva nr
ca — Coene2and Pero — Peno|utiun Rate
medx — K4ediumSund VV — VVe||
fo — Fine Sand Bldg — Building
|s — LoamySm�d — G,cn/m Than
°d — Sandy Loom / — LcnsThan
Loan` Bn — Brown
°oU — Si|t Loam 0 — g|mrk
si — Sill Gv _ G,ay
°o| — C|ayLuwm
sd — 8andvC|ay Loam R — R*d
'd
---(A Loam mot — lklutUo�
s dyC|uY mf — wiu`
u�c — 8|�v Clay Mf fevv. fine, fminT
°c — clay cc — omnmmn. c"am*
cu — mat mm — Many, medium
n, — K8uck d — distinm
p — prominent
HVVL — High,vvater ime|'
~ Sin general soil /rxtumo surfauc water
for |iquid waste disposal BM — Bench Mork
VRP — Vertical Reference Point
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TO THE OWNER: ,
This so!I test reporl is the first step in securing a sanitary permit, The county or the. Department may reClUest
myrUicadnn of this soil test in ihe field prior to Permit iSSuanou, A complete uu of plans for the private
� aewngo system and a pormi1 application mum be submitted to tho appropriate local authority in order to
� obtain a po,mit The ganitory permit must bn obtained and posted priurto the start of any construction,
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A
e r s PAGE OF
CrUS � eAlurl o � A Zito S S1
Fresh Air Wale And Observation Pipe
Approved Vent Cap
L Minimum 12"Above
Final Grade
20-42"Above Pipe _4"Cast Iron
To Final Grade Vent Pipe
Marsh Hoy Or Synthetic Covering
Min 2"Aggregate
0 of Pipe
olsirlbu Ito
n —Tee
Pipe _� 0 0 0 0 0
Be each Pipe 0 Perforated Pipe Below
Beneath Pipe
o —Coupling Terminating At
Bottom Of System
if
<;
����oSCD �In._1 c�rac�t
SOIL FILL
DISTRIBUT101.1 PIPE
APPROVED S.N'OpETIC COVER
MATERIAL OP 9" OF STFtAw
Za OF hG69 EGA1E -�� r OR MARSH HAy
1�'OF GGREGATE
LLEV. 0FC-?21FEET,
39 ��7
DISTRiMUTIOU PiPE TU BE AT LEAST WCHES BELOW ORIGIAIAL. GRADE
AUtj AT LEASTZO IMC14ES BUT MO MORE THAI) 42 IAICHES BELOW FIAJAL GRADE
MAXIMUM DEPTH OF EXCAVATiowi FKoM 0WI NAL 6RAO. WILL BE 1�15 INCHES
M141MUM AEPTM of EXCAVATION FROM 01K►GIaqL GRAPE WILL BE INCHES
SIGHED:
LICEAISE DUMBER:
j
DATE: a �'
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