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HomeMy WebLinkAbout038-1127-90-100 \ 0 69 I � � A � � I i � § � ] � � 2 � C J 2 7 2 � ) § � 7 @ � � ƒ $ 7 § E � f . I � § § a m i § � 0 C } k k ¢ D E ' co � � \ § ) ) a I z (n z \ m \ � 6 I « c — ■ \ 2 k IL ) / z k . � k L2 } E m ) � -� D a a a k \ § k k k z D0 � a � � / 2 °» m m % ' \ 5. 2 ° § \ 0 � & E = § § \ § ° § § § § % k §_ k k � \ k ) k k / k m % \ k § § k i U - § Cl) e ! I o z 2 R w ■ m � ® : . t § � \ E 2 0 , r 0 2a . , ' f� Form - S T C - 104 HC " /' ` AS BUILT SANITARY SY STEM REPORT OWNER F1 ey- //�� TOWNSHIP /�� Orcc//'�c� SEC. T ,�N-R �b V ADDRESS &X l /�, ST. CROIX COUNTY, WISCONSIN � Ai ee ` %5 t SUBDIVISION LOT --'LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p �M e iy / INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: e! / Proposed slope at site: G SEPTIC TANK: Manufacturer: 2 !L_e, Liquid Capacity: � Number of rings used: -�/ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: / Front, Side,O Rear, O �3y feet - From nearest property line ' Front,0 Side, Rear,O »» S _ feet Number of feet from: well//O building: /v 0 (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) /e±T fff1T..•.T ATT� PUMP CTMBER fanufacturer: 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: _ y Trench: Width: f�Z ` Length: 5"> "' Number of Lines: Area Built: Fill depth to top of pipe: J0 Number of feet from nearest property line: Front, O Side, Rear,0 Pt . 's Number of feet from well: &e) W e l Number of feet from building: (Include distances plot plan SEEPAGE PIT �z 4-4 3 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: Dated: �/�' 7 Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&,HUMAN F(ELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION aADISON,WI 53707 State Plan I.D.Number: NG!%,Npl%,S 31,T31 N-R 1861 CONVENTIONAL El ALTERATIVE If assigned) Town a4 Statc Ptf.a Aie ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound OLDER: ADDRESS OF PERMIT HOLDER: INSPECTION - 4SB Ptcanc,v6 Mondvtc Box 171A Somek6et W1 54025 0 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 Permit Number: B taut Bid Jtc. 3318 St. DLoix 119367 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER ) PROVIDED: PROVDED: aZ 54YES ❑NO ❑YES 5ZNO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF OA PROPERTY WELL: BUILDING: VENT TO FRESH D. ALARM: FEET FROM /1 LINT AIR INLET: EYES NO /l J 15 YES n-NO NEARESTM f V� DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: P PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑YES ❑NO ❑YES ❑NO I [:]YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑YES [:1 NO NEAR HST—DIAMETER: MATERIAL AND MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: 1\10.01` DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL` PIT DEPTH: �� DIMENSIONS J GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO ISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH B LOW PIPES: ABOVE COVER: E EV.INLET: ELEV.EN �I'� PIP FEET FROM LINE At/ AIR IN ET: !j y— 1 �r�r3 C7( NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED I DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV: ELEV: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑YES ❑NO I ❑YES ❑NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: d ❑YES ❑NO ❑YES ❑NO NEAREST----* J I � 4 Retain in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: SBD-6710(R.06/88) ZG SANITARY PERMIT APPLICATION COUNTY � DILHR In accord with ILHR 83.05,Wis.Adm.Code � . Gr° STATE/SANITARY PERM IT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES rX No PROPERTY OWNER I PROPERTY LOCATION a9 !.v'/a,Sl T , N, R/ E(or)OV PROPERTY WNER'S MAILING ADDRESS / LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY NEA EST ROA KE OR LANDMARK CITY,STATE ZIP CODE HONE NUMBER Q r�3 y X VILLAGE: err G II. TYPE OF BUILDING OR USE SERVED: IzA. 03? - /427-9/7-000 Number of Bedrooms if 1 or 2 Family Z OR ❑ Public(Specify): 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. E-1 Alternative c. El Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a.i9seepage 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): �' Q � ®r S Feet �Private ❑Joint ❑ Public VI. TANK CAPACITY Site in a llons Total xisting Gallons Tanks##of Prefab. Fiber- Exp . INFORMATION New Manufacturer's Name Concrete Con- Steel glass Plastic App. structed Tanks I Tanks Septic Tank or Holding Tank El El Lift Pump Tank/Siphon Chamber ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's S' ature:(No Stamps MP/MPRSW No.: Business Phone Number: 1,;qy�"od*n lge��s Address(Street,City,State,Zip Cod Name of igner: Vlll. SOIL TEST INFORMATION Certified Soil Te er(CST)Name ` ! CST#/ Y7 7 7 CST's ADDR S Street,City,State,Zip Code) Phone Number: An e r �� _ oa 6 76l IX. C NTY/ EPART ENT USE ONLY ❑ Disapproved S itary Permit Fee Groundwater ate Is ng Agent Signature(No St ps) S rchargeFee � C.C�/)OF Approved ❑ Owner Given Initial i e��\ `f Adverse Determination / W / X. COMMENTS/REASONS FOR DISAPPROVAL: ci 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; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE I 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- Grouted �"r included the creation of surcharges (fees) for a number of regulated practices which Wisco iJt'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried is used in your building is returned to the groundwater through your soil absorption e system or the disposal site used by your hording 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 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 kin c,S' Location of property , 1/9 1/4, Section T N-R W Township W-1 Mailing address Address of site .SaIxf Subdivision name Lot number Previous owner of property /i//�l/lt � /�'/ldl/�/1P - Total size of parcel 271 Date parcel was created &71)11 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house)? Yes ✓ No Volume V3 and Page Number qty 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 ences 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. 27 f 9�7• ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. r tzgZ�aturp of Owner Signature of Co-Owner (If Applicable) //,/ 15ZLZ Date of Siglfature Date of Signature No.S-1. Warranty Deed--0ommoa Form (STATZ OF WISCONSIN) Sec. 285.18, Win Statutes. Form No.1 PubUd"b 1aa Mira Book A Stat MM Co. 27 �+a This Indenture, Made this '15 day of April ,A.D.,1963 between Mitchell F. Mouchet and Helen J. Mouchet, husband and wife, and each in their own individual capacity, • part i e s of the first part,and Francis D. Mondor, a single man, • part y of the second part. WitntOttb: That the said parties of the first part, for and in consideration of the sum of Thirteen Thousand Five Hundred Dollars 013,500.00) to them in hand paid by the said part y of the second part, the receipt whereof is hereby confessed and acknowledged, ha Ve given,granted,bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said part y of the second part, his heirs and assigns forever,the following described real estate,situated in the County of St. Croix and State of Wisconsin,to-wit: The Northwest quarter of the Southwest quarter (N'44SW4) and the Southwest quarter of the South- west quarter (SW;'_-SW4) of Section "30" , Northwest Quarter of Northwest quarter (NW4NWs) of Section "31" , allin Township Thirty-one North (T31N) of Range Eighteen West (R18W) , and the South half of the Southeast quarter (SJSE4) of Section "25", Township Tlpirty-orB North (T31N) of Range Nineteen West (R19W) . Cogttbtt with all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining; and all the estate,right, title, interest,claim,or demand whatsoever,of the said part of the first part,either in law or equity,either in possession or expectancy of,in and to the above bargained premises and their hereditaments and appurtenances. Zo Rabe anb to PoIb, the said premises as above described with the hereditaments and appurtenances, unto the said part Y of the second part,and to hi s heirs and assigns FOREVER. Ana the 4&atb Mitchell F. Mouchet and Helen J. Mouchet for themselves, theirheirs,executors and administrators, do covenant,grant, bargain and agree to and with the said party of the second part, his heirs and assigns,that at the time of the ensealing and delivery of these presents they are well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever, and that the above bargained premises in the quiet and peaceable possession of the said party pf the L A o gyp,►,.., Cb n 1 ! S 2r Cb i b i°C' ti n °b 43 tr o p ti a a. , d b b N c tv G Nip p. b Cb off fo oomun ea nooaogs UMVA*dt4 ao pyu)sd tiury)a "wq[logv lq oM N 4*gU*U&4m F al*vlp"pl—moss*"A sst*ggo—,IrK)a`Jy I •uTsuoos TM opaomqoTu mem ImRl qe s auaoggV wsgqWnH ;g saij7nH 'q pa;;gsQ • E96T '•a'-v' ( aunr rasrdza uorrsruriuoa SR 'UNWORNj�6;uteoo 'arlgnd Liv;oN • •` •'tix l ti pa8pal &OU.V"pug;sxaumi;sur 8 aso;aq;pa#uaaza oq.A g uosiad aq;aq o;u r►ou$our o; `A4Toadao TgnPTATPVfT uMO JTag4 uT qoQA pas `a3TM pu `'3uegsnq `gagonow •r u9j9H pue gagonoW *a TTagogTw Parueu aeogv aq; £9 6T"a'Y T T adV ;o A&P p srq;'our a ro;aq arose Slleuos.rad •ss 4111Ou930 30 4930 H W 4a .0 (Ives) s9WnH *M ttdasOP qaqunow -r aLjonow 71.10 o (Ives ._..r... . i' ;o a3u9said q pelves-Pug pau8rs • C9 61 s•a•Y 1 T';ady ro Lgp 21, srq; g lgas pug 8 puvq .I T G Liq ;as o;unasage A gg;jed ;s rg eq; fo s q T ugd p!es aq; 430MQM Oljn; uit 'aN,Ydza Pug .Lmvzr4vvAi aaeaio; ma A9TAq 'joa:aq; ;.rvd rtue so alorles aq; 8urutrgla dlln;asel 'suosaad !o uorsad d raAa pug 1p ;sam2v 'suftsa pug s.rraq g T U ';.red puoaas ion STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER I"G12 IS 94z/-- ROUTE/BOX NUMBER �� &_X 1714 FIRE NO. CITY/STATE SiMersrf A111 ZIP PROPERTY LOCATION: 5AI 1/4 l/A/ 1/9, Section _ N, R_1z 4F(_W, Town ofQir /4-f f/'e , St. Croix County, Subdivision , Lot No. i 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 Zoning Office within 30 days of the three year expiration date. SIGNED DATE 3 d 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& BUILDINGS INDUSTRY, LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 a HUMAN RELATIONS MADISON,WI 53707 LHR 83.09(1) &Chapter 145) LOCATION: SECTION: "4T OW NICIPALITY: LOT /T NO. BLK1_.N O . UDIVISION NAME: � N/R E (o OUNTY: OW ER'S B ER'S AME: ING ADDRESS: r- G ' / fn e r / r USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: P PER OLATION TESTS:Residence y ' New ❑Replace /'i 1 J�4 d.�-- / l./ o RATING:S=Site suitable for system U=Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: ®s ❑u rOs ❑u US [:]U ❑s u ❑s u 6 I If Percolation Tests are NOT required DESIGN RATE: 4 I If any portion of the tested area is in the under s. ILHR 83.0915)Ib),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 OBSER ED (SEE ABBRV.ON BACK.) ` ! B- f s ot B B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIODg PER PER INCH P_ l 0-eL C (q P_ p G P- P- P- /� PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitabl �rea`�nT dicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show I(8/s&f%E elevation at all borings and the direction and percent of land slope. irlYt�/J SYSTEM ELEVATION 7Cl 1 , I IN _ Sfax -r/ j4�' tj I,the undersigned, hereby certify that the soil tests reported n this form were made by me in accord with the procedures and methods specified in the Wi consin 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 0 ADDRESS: _ CERTIFICATION NUMBER: PHONE NUMBER(optional): d r !J o 7 �P' CST SIG TU E: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) —OVER — l INSTRUCTIONS FOR COMPLETING FORM 115 - SRD - 5395 To be a complete and accurate soil test,your report must include: 'I. Complete l gal description; 2. The use section n!ust clearly indicate vdiether this is a residence or commercial Project; 3. MAXIMUM number of bedrooms or commercial use planned, . Is this a now or replacement system; S. Complete the suitability rating boxes.A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL CT- ER SYSTEMS ARE RULED O UT LASED ON SO I L CON DITIONS; 6. PLEASE use the abt)reviations shown here for writing profile descriptions and completing the plot:plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate=sheet may be used if desired; S_ 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- 6on, if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box; 11. Sign the form and plane your current address and your certification number; 12, Make legit:}le copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR Bedrock cot) Cobb!e (3- 10") SS Sandstone gr - Gravel (under 3") LS - Limestone *s Sand HGW High Groi.undwater c - Coarse Sand Perc - Percolation Rate €ned s - Medium Sand W - Well fs Fine Sand Bldg Building Is - Loamy Sand > Greater Than *sl - Sandy Loam < - Less Than *I - Loam Bra - Brown sit Silt: Loam BI Black si Silt Gy - Gray %cl - Clay Loam Y .. Yellow scl Sandy Clay Loam R Red sicl -- Silty Clay Loam mot Mottles sc Sandy Clay VV/ - with sic - Silty Clay fff -. few, fine, faint *c Clay cc common, coarse pt - Peat mm - Many, medium in - 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 I II 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. J PROJECT 6r5 r ADDRESS APR§11/4 Gtr 1/4/S 1/T�/ N/Fj/ W TOWN Y� c COUNTY Byron Bird Jr. 3318 DATE BEDROOM CLASS PERC CONVENTIONAL, IN-GROUND P SURE CONVENTI NAL LIFT MOUND—HOL NG TANK SEPTIC TANK SIZE paw LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA --� PERC RATE ,/.� BED SIZE 6-3 / IL Benchmark V.R.P. Assume Elevation 100' Location of Benchmarkte," ❑ Borehole Q Well Scale = Feet O Perc Hole System Elevation © . S� Vent 12" Grade TYPAR COVERING 2" 12" 3' 4 6' O 3' 3' O 3' 1 6" Sewer Rock 12' 18' -—�t fe e- Ile Q