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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 11T,'e TOWNSHIP LtZ SEC. _ T rN-R / W
ADDRESS Ta- G/t/ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION .��,�� �:` LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
v✓
r6 ,
5�p
to
NS
v
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used �i 'e
Elevation of vertical reference :oint
p GJ�, Proposed slope at site: 3 l
SEPTIC TANK: Manufacturer: Liquid Capacity•
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,(D Side,o Rear, 0 r� feet
From nearest property line Front,0 Side,O Rear,O feet
Number of feet from: well .S-y , building: 1,:5� `
(Include this information of the above plot plan)( 2 reference dimensions to septic "
SEE REVERSE SIDE
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).
i
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: % Length: Number of Lines: Area Built: -Ed
Fill depth to top of pipe:
Number of feet from nearest property line: Front, .O Side, Rear,0 Pt .
Number of feet from well: /t�" -
Number of feet from building: 4� '
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of its: Diameter:
i p
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: Jj��7��_� Plumber on job:
License Number: Z'7
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
NE4,SE4jS6,T28N-R19W 000NVENTIONAL ED ALTERNATIVE StatePianl.D.Number:
III assigned
Lot 2 Nordic Heights ❑Holding Tank ❑In-Ground Pressure ❑Mound
Town of Troy
NAME-OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION D TE:
Ronald D. Antiel Hudson, WI 54016 a�+$g � l O
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELE V..
Name of Plumber MP/MPRSW No.'. Countv'. Sanitary Permrt Number:
William Schumaker 6382 St. Croix 106052
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIDUID CAPACITY'. TANK INLET ELEV.: TANK OUTLET ELEV.'. VROVIDEDLABEL PROVIDED OVER
YES ONO ❑YES `ONO
BEDDING. VENT DIA.. VENT MATL_ HIGH WATER NUMBER OF ROAD. PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM O LI� I
NE AIR INLET
FEET FROM
❑YES�NO ❑YES UNO NEAREST
DOSING CHAMBER:
MANUFACTURER T10YEs DING LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARN LABEL LOCKING COVER
OV ID PROVIDED.
ONO YES NO ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL ING VENT TEFRESH
LINE AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check thesoil moisture at the depth of plowing I LENGTH DIAMETER MA RIA NDM R NG
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 SPITS LIQUID
BED/TRENCH TRENCHES ( MATERIAL! PIT DEPTH
DIMENSIONS 4to
GRAVEL DEPTH FILL DEPTH UISTR PIP' DISTR.PIPE DISTR PIPE MATERIAL: NO.DI R. NUMBER OF PR OPERTV WELL. BUILDING VENT TO FRESH
BE OW PIPES ABOVE COVER. ELEV.INLET EpLE V.END'. PIPES FEET FROM LINE �� �� AIR INLET
II 4- L�" a� 3 NEAREST 1�C� 64 1�
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 ONO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
EY ES ONO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES ,
DYES ONO OYES ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF. FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP I V ANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR OISTR.PIPE DISTHIBUTION PIPE MATEHIAL.&MIA HKIN(,
ELEV.. ELEV, DIA.. ELEV. PIPES
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING. GRILLED CORRECTLY VER MATERIAL
PLANS
DYES ONO OYES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PRO PE RTV WELL'. BUILDING'.
OOMM LINE.
3 FEET FROM
❑YES ❑NO ❑YES ❑NO NEAREST
t
,tom
I
3
Sketch System on l y Retain in county file for audit.
Reverse Side.
-SIGNATURE. TITLE.
Zoning Administrator
DILHR SBD 6710(R.01/82)
CO""
SANITARY PERMIT APPLICATION
TUILHFR In accord with ILHR 83.05,Wis.Adm. Code , C�v�
STATE SANITARY PERMIT##
/v Gas
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUM ER
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 �NO
PROPERTY OWNER PROPERTY LOCATION
� � =1/4 $r_ - 1/4, S T �N, R E(or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBBJDIVI I NAME y
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
c►
4j,- ��%!�/ -r VILLAGE
II. TYPE OF BUILDING OR USE SERVED: ' CK/0�O�d
Number of Bedrooms if 1 or 2 Family. OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. KNew b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum.requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2)
1. a. Koonventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. K Seepage Bed b. ❑seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
Q eZ� �� Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total ##of Prefab. Fiber- Exper.
INFORMATION New osting Gallons Tanks Manufacturer's Name Concrete stCon-d Steel glass Plastic App
Tanks Tanks _ j
Septic Tank or Holding Tank k ❑ ❑
Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑
V11. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No Sta ps) P�MPRSW No.: Business Phone Nu>mber:
r/1 i�A iG tL .�-- .1 (O < v!
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
^
s -
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST##
e'-1—$;;7 F
CST's ADDRESS(Street,City,Sta ,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved a itary Permit Fee Groundwater [T_r�ovvl Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial S}fryeharge Fee Adverse Determination 0, XS'�
X. COMMENTS/REASONS FOR DISAPPROVAL:
fa-h C pW4 h-,c �1 ITT
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; weVs; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground
included the creation of surcharges (fees) for a number of regulated practices which Wisco lrtx$
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re d4i 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.
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-
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 �Levii LD n, 17RJ7-IC& v2 LO/{i�_rL�._' JPl, AAc '7
Location of Property 1% Section , T L_*' N-RL2_ W
Township 7_k 0`'
p�sServc !�
Mailing Address 7 OD �'` S i A,1, �4 PF, ,
Address of Site
Subdivision Name !V 6knt L kE16 y7S'
. Lot Number oZ
Previous Owner of Property Sal dYl jC �L
Total Size of Parcel �2 j O 4 L/`� S
Date Parcel was Created /U 0 yr 122 /5/ 7f
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume T7 3 and Page Number ;2- -7 as recorded with the Register of Deeds.
DoC4L10G� � ¢� 3 7:7- 6
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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
1 (We) ceA i.6y that at,t 6tatement6 on this 6okm arse trcue to the best o6 my (ours)
hnowte e; -that 1 (we) am (arse he owners
d9 ) (6) o6 the pno ent de�sehi-bed in zhie
p y
.cn6o4mation 6o4m, b v- tue o a waAAant deed tecotd d
y 6 y e in the 066tiee 06 the
County RegAAterc o6 Deedsa6 Document No. and that I (We) p4ezentty
own the pnopo6ed zite 6oh the 6ewage d.i.6pod 6 y6 em (ore I (we) have obtained an
easement, to nun with the above de6cAibed ptoperrty, bon the eon6trcucti-on 06 6a.id
4y6,tem, and the Game ha6 been duty Aeeohded in the 066ice o6 the County Reg.c.6terc o6
Veed6, ab Document No. ) .
c _
SIGNATURE OFD OWNER SIGNATURE CO-OWNER (IF APPLICABLE)
��j ��
DATE SIGNED DATE SIGNED
4y.
1
DOCUMENT NO. STATE BAR OF 'WISCONSIN FORM 1-1982 THIS 4PACS R4SARVE0 FOR RECORDING DATA t
WARRANTY DEED
412372(; , 600K 773 ui REGISTERS OFFICE j
Sam E. Miller, a single
SL CROIX Co., WI,%
This Deed, made between ---------------------- ----------------------------------- Recd, for Record this 26th
man . ------•-••---•-------•-•.... ....................... .................... day of March
- ---------------------------------- --
--•--- y aD. 1987
...........................................................i M.----•••--- --•- -- , Grantor, 1 :45 P
and_._Ronald D. Antiel and Mariyn . Antlel, husband
and wife
--------------------------------•-- •-••-••-•-•----••---------•---•--•--------------- _"S_-14_Q 1�
hoWn M pjod�j-�
--------------------•------•---------,--------------------------------------- ----------- Grantee,
Witnesseth, That the said Grantor, for a valuable consideration_-_---
.............. •-•--•--•--•-•-------••---••---•--•-•--------•---- ----------- ••-•----•--••----=-••-•-......-•--
St• Croix RETURN TO
conveys to Grantee the following described real estate in ----- -
County, State of Wisconsin:
Lot 2, Nordic Heights l_
Tag Parcel No: ...................................
4
I
1�Y:c11` S
C
FEE
This i_s not.------ homestead property. '
($) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And......Sam E. Miller
..............•-•-•--•--• ------------------ --•---••-----•-----•--- .........................
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and protective covenants or restrictions of record, if any,
and will warrant and defend the same.
Dated this 26th.......................... day of March ...... .. ... ..., 19..87... ( f
.
(SEAL) ... •-•-••--.....(SEAL)
..•... ...................... _----• ••. . ` . Ju ! I,
* * Sam E. Miller
-••-----•-•.........................................••••---....... .• .................................
(SE ........ ....... ...............................(SEAL).
i
* * .•--•-- -•-- .............. ..... -•-.. ..
i
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ------------------------------------------------------------
STATE OF WISCONSIN
ss.
-------------------------------------------------------------------------------- St. Croix
----- --------- County.
authenticated this ........day of--------------------------- 19------ Personally came before me this ----------day of
March 19_.8 _. the above named
-------------------------------------------------------------------------------- Sam E. Miller
*------------------------------------------------------------------------------ ----------------- -------------------- --------------------------------•--
TITLE: MEMBER STATE BAR OF WISCONSIN ...........
(If not- ------------------------------ ----------------------------- ......----•----••------••-•-......_..------.....................--•-•------•-•°
authorized by § 706.06, Wis. Stats.) to me known to be the
xson ............. who executed the
for ing instrument,�& nowled a the same.
THIS INSTRUMENT WAS DRAFTED BY .. � •n; ��'- a
.►it' _. . .._
:7.�ds..p,.•- uxray_•of.-4g_yjK od ..Cari & Murra
son WI 54016 �--•-----------------------
------------------------------ Notary Public __.=.. ew 1 ------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission i ptl. 4:11ot, state expiration
are not necessary.) date• Apri ��ti 8/N
'Names of persons signing is any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin I,eRal Blank Co. Inc.
FORM No. 1—1982 - Milwaukee, Wis.
M
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9TC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County x
c7
/�
OWNER/BUYER NALD D'Akr'ICL, e32 �I,f�<2rLyA/ 1U1; d�K/TICL to
ROUTE/BOX NUMBER 531 ���� �d � Fire Number
.CITY/STATE —Aad--son W" ZIP 6
PROPERTY LOCATION: 4, 5E k, Section, T �Ly_N, R ly W,
Town of St . Croix County ,
Subdivision /l)oX_pj L &7 IG#TY, 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 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 .
0
E
I/WE, the undersigned , have read the above requirements and agree y
to maintain the private sewage disposal system in accordance with x
rr
the standards set forth , herein, as set by the Wisconsin Depart- a
ment 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. y
S I G N E D
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.
�'.-�M Q,��G� h'�►�.-fi- 7`o T',y ��..s— D��1 �v—a 9�9 �
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
'LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
MADISON,HUMAN RELATIONS SON,WI 53707
(H63.090)& Chapter 145.045W Q/-I Av$ruM S4et 3`1- r
T TOWNSHIP/ LOT+�NO.:BLK.NO.: SUBDIVISION NAME:
LOCATION:E 1/ ,/ /T,2�HjR� �(Or re Y r�
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: //
,.Sr t .� wt �`.//� )w �i'rb/c ��� �Iv� cFs. �YcY
USE DATES OBSERVATIONS MADE
NO.BEDRMS : C MM ICIAL D5SCRIF TION: PROF DESCRIPTIONS: TESTS:
Residence /II New ❑Replace /'I_ �+ �q /6 Q_ 9
y
6- 7�3 B =.� �e /
RATING:Ss Site suitable fora stem U=Site unsuitable for system
ONVENTI NAL: MOUND: IN-GROUND-PRESSURE: Y T IN-FILLHOLDINGrTAANK: ECOMMENDJEDSYSTEM:(optio�`a1)
®-S ❑ M ❑U S ❑U ❑S ICU ❑S cud T'e ,�-e-c�
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain, indicate Floodplain elevation:
P FILE DESCRIPTIONS
BORING TOTAL P H T R UN DWATER.1•PIQ4E-9 C14ARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED ES IGHES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- ) ,0` /00.0f 7 ��� • JV B/S) Bet S l 4*• � 'Bh S
B- jeA
i
B' Sr .o' �ati. 6 ` Dace > .0' .V S /. �l'Sn S .0 �n S
B- G ,0' 9 7, 7' eve. 7 a ! l r n s l �, �� S
PERCOLATION TESTS
TEST DEPTH# WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 4NGW $ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PER INCH
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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 96• _- __-� G L.
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1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE D COMPLETED
ON:
esRS� r :r ��fe � ,2 -- Q 7
ADDRESS: / CERTIFICATION NUMBER: PHONE NUMBER(optional):
��— JCSTSIGIVTURE.
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DISTRIBUTION:Original and one copy to Local Authority,Pro r weer and Soil Tester.
DILHR•980-6395 (R.02/62) —OVER --
EH 115 Rev.9/78 '
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
• WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O.BOX 309,MADISON,WISCONSIN 53701 r: -
LOCATION.. 'f '/4,`--°%r %,Section ,T_N,R=E(or)W,Township or Municipality r
(f a''. G" 3lJi Y
Lot No.— , Block No. { ' ; County b. ---
ti Subdivi sion Name
Owner's/Buyers Name:
Mailing Address:
TYPE OF OCCUPANCY: Residence Y No.of Bedrooms COMMERCIAI "
EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM'. --OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS ," '�/ PERCOLATION TESTS',,
SOIL MAP SHEET NAME OF SOIL MAP UNIT��y • !� S.V%'fir `r''
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP tN WATER LEVEL.,INCHES
NUM- DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTE INTERVAL RATE
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PE000 PERIOD 2 PERIOD 3 MIN/IN
P— �� ,, ; 7:�' ', z
P-
P_
P—
SOIL BORING TESTS '
TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WIT"THICKNESS,COLOR,
TEXTURE,MOTTLING A�p DEPTH TO,BEDROCK
NUMBER . INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHE
B_ tee
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PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on theplan Pje locWoWand-square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type occupancy : .n/,�ir�.a r ti}Indicate scale or distances.
Give horizontal and vertical reference points.Indicate slope. /
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1;the undersigend,hereby certify that the soil tests reported on this form were made by me in accord 11�ith',the procedures and methods
specified in the Wisconsin Administrative*Code,and that the data recorded and location of test holes ; ;gip the best of my
knowledge and belief.
Name (print) .+„ 4lltr _: � ^Certification
p
Address �
Name of installer if known
CST Signature , •'? r
Copy D—File Copy For Soil TesEer Y
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REPORT OF INSPECTION_INDIVIDUAL SEWAGE SYSTEM
San.i.Zany Penm.i
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State Septic 75�
NAMES . I'ownah.ip St. Cno.ix County
Locat.iorr� L ,{/e Section _
SEPTIC TANK y�
Size ga.t.tona . Numbers o6 Compantmentb I
ViAtanee FAom: We,t.t 12$ on greaten e.tope it
Bu.i.td.ing 6t. Wet.tand.6 � •
Highwaten a fit.
DISPOSAL SYSTEM
D.c.dtanee Fnom: We,t.t #. 12$ on gneateA a.tope 6t.
Bu .tding 6t. Wet.tand.b Ft.
i
• Highwaten fit.
FIELD DIMENSIONS:
Width o j' then ch it. Depth o6 Ao ck b e.tow t.i.te in.
Length o6 each tine it. Depth o6 Aoek oven Cite .in.
Numb en, o 6 tined Depth o s t.i.te b e.tow grade .in.
Totat, .Length o6 .t.ined St. S.tope o6 trench in pen 100 , 6t.
D.cetance between .t.ine.6_4t. Depth to bednoek fit.
Totat abaoAbt.ion area 6t2 Depth to groundwater fit.
Requited area 6t2 Type o6 Coven: Paperi on Straw
PIT DIMENSIONS:
Numbers ob p.itz Gnave.t around p.ite ye4 no
Outa.ide d.iameteA fit. Depth be.tow .in.tet fit.
2
Totat abzonbt.ion area 6t A
Area %equ.ined 6t2 ^'
INSPECTED BY TITLE
APPROVED ,DATE 197
REJECTED ,DATE 197
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FF EH - 1.15 Rev.9/78
` REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309,MADISON,WISCONSIN 53701
LOCATION:'/a;5'X,Section ,,`T- N,R/� r or j0,Township or Municipality T�7 y
'Ale, c��`C C?/,�"� Count �c i—el,x
Lot No. , Block No. Y
u iw on ame
Owner's/Buyers Name:
c
Mailing Address: /d , ,� ,t •
P - �� Cc./e_, c _ / ') Z
TYPE OF OCCUPANCY: Residence X No.of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS Id -'27' 7j PERCOLATION TESTS
SOIL MAP SHEET - NAME OF SOIL MAP UNIT-9k
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NUM- SINCE HOLE HOLE AFTER INTERVAL
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P– / YJtr fee Pere A/C -3 � � 6 • s'
P— /w" SCE ? U 3 (� • SJ
P— 3 S�x- rP 04 f 4(0 _3
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,
TEXTURE,MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B_ c Oil e- rq'3� ,,s/ kpf�
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on t e Ian the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy �,• p�`' .Indicate scale or distances.
Give horizontal and vertical reference,points. Indicate slope.�!) S�z� f��lc *--*q'
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1,the undersigend,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 location of test holes are correct to the best of my
knowledge and belief.
V)
Name (print) kAiAlg � liz' 1r-s e' Certification No. -5—S -
Address
Name of installer if known
Copy A—Local Authority CST Signature
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State and County State Permit
PLB67 Permit Application County Pe #
for Private Domestic Sewage Systems Count
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: VE % Se %, Section �, T_,?k N, R-" k (or) ® Lot# —City_
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
_ c r all c, e.rs
C. TYPE OF OCCUPANCY: *Gbmmercial *Industrial *Other (specify) *Variance
Single family < _ Duplex No. of Bedrooms 3 No. of Persons 37
D. TYPE OF APPLIANCES: Dishwasher _K YES NO Food Waste Grinder YESXNO # of Bathrooms
Automatic Washer { YES NO Other (specify)
E. SEPTIC TANK CAPACITY �/=Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation X Addition Replacement— Prefab Concrete X
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _,S 2) 3) _Total Absorb Area -$S sq. ft.
Newer Addition Replacement *Fill System b I '�e�G���d
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length 3(9' Width /_Depth y8„ Tile Depth 36 No. of Lines —_
Seepage Pit: Inside diameter Liquid Depth Tile Size yp
Percent slope of land Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester
NAME ►3 P. If 'x lz>o Ae/5cn C.S.T. # _ 51- /sJ and other information
obtained from a (owner/builde
Plumber's Signature<5Z � MP/MPRSW# MP���'� � Phone # - 61-7 0
Plumber's Address SO(A m 0 N P,O f - -E k-cL 5-'CQ U- i S C Cl f rs
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
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Do Not Write in Sp cf ow R DEPARTMENT U/� ONLY �J r
Date of Application 1 l Be� Fees Paid: State /�Co2pw T 0 O Date 1
Permit Issued/ (date) ��-1 Issuing Agent Na
Inspection Yes No Valid# Date Rec'd
h' a
1. county (w copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1/76