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Parcel #: 040-1211-90-000 07/15/2005 03:14 PM
PAGE 1 OF 1
Alt. Parcel M 07.28.19.1008 040-TOWN OF TROY
Current X ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): *=Current Owner
*MAYEK,TIMOTHY J&DEBRA A
TIMOTHY J&DEBRA A MAYEK
310 W GROVE RD
HUDSON WI 54016-0000
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *310 W GROVE RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.005 Plat: 2597-WEST GROVE ESTATES
SEC 7 T28N R19W LOT 9 WEST GROVE ESTATES Block/Condo Bldg: LOT 09
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-28N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
01/10/2000 616704 1483/169 WD
07/23/1997 2000/520 WD
07/23/1997 812/429
07/23/1997 800/507 more
2005 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/22/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.005 87,800 318,100 405,900 NO
Totals for 2005:
General Property 2.005 87,800 318,100 405,900
Woodland 0.000 0 0
Totals for 2004:
General Property 2.005 87,800 318,100 405,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 518
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
r
Ar Fo rm - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER mOSe Nol'1�� TOWNSHIP SEC. _ Tp_N-R 1. J
ADDRESS J� Lawvit ST. CROIX COUNTY, WISCONSIN
SUBDIVISION W, GKo ' _ LOT 9 LOT SIZE
E's etc S
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83 W` T IY
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3
� 3/
5�� o
O
O lo'_ IS•
�x3(, Bed
N
T
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used G RbU U� N e X �h Sfe e� e mcl�
�ost
Elevation of vertical reference point: 00.0 Proposed slope at site: 9 6
SEPTIC TANK: Manufacturer: We.e K S Liquid Capacity: (00 0 J AI
Number of rings used: �_ Tank manhole cover elevation:
/o3. 5 g
Tank Inlet Elevation: ,y Tank Outlet Elevation: %J 7
Number of feet from nearest Road: Front,O Side, Rear, O 150' feet
='— From nearest property line Front,O Side,®Rear,O _ V I feet
Number of feet from: well �, building: /71
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
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 dista�`c s qn�?lot plan).
aha ' o.00 �oy.�5 �N� - 9Y.3 - 9v. 31
SOIL ABSORPTION SYSTEM �'�' 4�3�Ya
Bed: V Trench: Bel
Width: + � Lenth: Number of Lines:_ Area Built:
Fill depth to top of pipe: y �1
Number of feet from nearest property line: Front, '®Side, O Rear, Ft .
3'
Number of feet from well: q5
Number of feet from building:
(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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
p Inspector:
Dated A I�0 g Plumber on job:
License Number: JP R S d3 t 0
3/84:mj
i
DEPARTMENa`OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
P.O.BOX 7969
MADISON,WI 53707
SW14, SA, S7,T28N—R19W YffCONVENTIONAL ❑ALTERNATIVE OF'slaned) .Number:
111 asslgne0)
Town of Troy ❑Holding Tank ❑In-Ground Pressure ❑Mound is"
Lot 9 West Grove Estates
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: /
Moser Homes 213 Locust Hudson WI 54Q16 / "L
REF.PT.ELEV.: CST REF.PT.ELE V..
BENCH MARK(Permanent reference Dointl DESCRIBE IF DIFFERENT FROM PLAN:
Name of Plumber IMPIMPRSW No.: County: Sanitary Permit Number:
Richard Hopkins
1059 St. Croix 102856
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED
1660 iko 4�T �� YES ❑NO QYES
�NO
ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
BE DD WG. VENT DIA.. VENT MATL: HIGH WATER NUMBER OF `� LIrEV 1 (AIR INLET
ALAHM FEET FROM C�
DYES NO � ❑YES rNO NEAREST
DOSING CHAMBER:
MANUFACTURER B7DD NG: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
ROVIDED-. PROVIDED:
ES ❑NO YE ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF P ER TV WEL BUILDING VENT LOT FRESH
FEET FROM L
(DIFFERENCE BETWEEN
PUMP ON AND OFF) I OYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAME ATE IAL D MARKI
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. 7;����COVER INSIDE DIA -PIT p pTIH
BED/TRENCH "tATERIAU PIT
DIMENSIONS (I 3
GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DI NUMBER OF PR OPERTV WELL BUILDING VENT T E FRESH
BFGW PIP ABOV COVER. E EV;N�ELEV.;N� PIPE$. INE AIR INLET
t, 44 vj( FEET FROM j� � �rx'^J•r•
NEAREST
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.
OYES ONO
PERMANENT MARKERS OBSERVATION WELLS
SOIL COVER TEXTURE
OYES ONO F-1 YES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED S MULCHED
CENTER EDGES
DYES 0 N ONO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE UISTHIBUTION PIPE MATERIAL&MAHKING
ELEV.: ELEV.'. DIA.. ELEV.. PIPES
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
OYES NO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVA7Y E S WELLS. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
1
: YES ENO ONO NEAREST
1
1
Sketch System one Retain in county file for audit.
Reverse Side. TITLE.
SIGNATURE
Zoning Administrator
DILHR SBD 6710(R.01/82)
SANITARY PERMIT APPLICATION COUN C
LJ ERLHM In accord with ILHR 83.05,Wis.Adm. Code ✓ '
STATE SANIIT�A�R^Y PERMIT
/Q�O�7
—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 jj��
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ y •�YES NO
PROPERTY O NER PROPERTY LOCATION
(SS 5W '/45 W'/4, S T g, N, R E (or
PROPERTY OWNER'S'S MAILING�fSS LOT N BER BLOCK gBER SI IB
CI STAS DIVI ION ME
C 4 ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
❑ VILLAGE:
ON
�( I Q
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): a V
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. Wonventional 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. Xseepage 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): PROPOS D(Square Feet):
4 S I (o 13. Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total ##of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank _LJ7_
Lift Pump Tank/Siphon Chamber ❑ L1
VII. RESPONSIBILITY STATEMENT
1,the undersigned,assume responsibility for installation of the private sewage stem shown on the attached plans.
PlumIZA' e(Print): Plu Ws ignatur (No�S) MP/MP RSW No.: Business Phone Number:
1Ki6 ►NS fv 6 75 38La�
Plu a s Add s(St eet, ity,Sta e,,Zip ode): a of signer:
VIII. SOIL TEST INFORMATION
Certified So'I Tester( T)Na e , ` CST#
ml q W
CST's_AD E 4(Strpet,City, late,Zi ode U f Phone Nur e�
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
Approved F-1 Owner Given Initial 'J� ur charge�/Fee
� p
Adverse Determination /`�"w �
X. COMMENTS/REASONS FOR DISAPPROVAL:
pfal, Cty2j0ra- W hj I hoh-el-o C. fie ISon
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
� 1
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 neededi
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. It you have questions concerning your private sewage system, contact your local code administrator or the
Srtate of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
!. P,,operty 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;
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/Departmb'nt Use Only,
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'h 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 robins/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.
------------------------------------ ---- --------- -------------------------- ----------- ------------------------------------)�-- ---------- r
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into ':aw. This legislation is more �
commonly known as the,,g4oundwater protection law. This change in statutes was the
i
result of over 2 years of steady negotiation and public debate. The groundwater bili? ' `Ground
included the creation of surcharges (lees) for a number of regulated practices which Wisco iR`a
can effect groundwater. The surcharoe� took effect on July 1, 1984. All of the water that Gtjried reasure
Is use,' in your building is returned t:; the groundwater through your soil absorption
o
systerr or the disposal site used by your holding tank pumper.
a
The Monies collected through these surcharges are credhed to the groundwater fund adminis
te-rec! t,y the department of Natural Resources. These funds are used for monitoring ground- t
v::ate gr;ur•dwa!er contarniriatic:-o in,estigati•ons and establishmerit of standards. Ground,A,atF! _ 7
arc_-th protecting_
D-ei393(�.U3 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/contracts?-C, ("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 Moser Homes . Inc .
Location of Property 0 W k !�w �, Section 7 , T ZY N - R / OW
Township Trov Townshin
Mailing Address 213 Locust St .
Hudson , WI 54016
Subdivision Name West, Grove Estates
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes _ No
Volume 80D and Page Number 507 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICA'T'ION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) eeAti 6y .that aQ,e atatement6 on this 6onm ane tAue to the but 06 my (oun)
h.nowtedge; .ghat T (we) am (au,) .the owgeA(h ) o6 .the pnopenty de6cA bed in .thi,6
.in6on,liati.on ;6onm, by vi tue o� a wafAcarcty deed neconded in the 066.ice o6 the
County Reg i a tee 0 6 Deeds " Document No. i �5 '� ; and that I (we)
)
p4e�sentZy oun the p4oposed .6.ete bon the .sewage c.spols eyatem (on 1 (we) have
obtained an eas emen.t, to nun with .tile above dv s cAibed pnopen ty, bon the
con.6t)cucti.or, o6 said dybtem, and ,the same hays been duty kecoitded in the 066ice
o6 .tile Coumy Regi4ten o6 Deeds, as Document No. 1 .
SIGNATURE OF OWNER SIGNATURE' OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED \
__. _ ... ,
DOClfMENT NO. STATE BAR OF WISCONSIN—FMM 1
z I
800 O PAf 507 THIS i �� OATH
433572 �0 K
Sr. CROIX CO.$ WI
Reed for ne
THIS DEED, made between Rue R. Elston and Clara L.
d
Elston, _husband and wife, Tart 1488
� 3;40 P M
and Wayne F. Moser and Murray A „�necht, as Grantor_
tenants in common,
Rsoderef 0"
Grantee,
Wi t n e s s e t h, That the said Grantor, for a valuable consideration One
0.1 00) Dollar and other valuable consideration MULMNTO
moveys to Grantee the following described real estate in St. Croix
,,aunty, State of Wisconsin:
Lot Nine (9) , Plat of West Grove Estates
in the Town of Troy. Tax Key No.
Together with and subject to easements , covenants , reservations and
restrictions of record.
CR.ANSFER
Transfe!.r Fee previously paid
J '
This_-i—s- not--homestead property. `
q Together with all and singular the hereditaments and appurtenances thereunto belonging;
4
And . Rue R. Elston_ and Clara ..L. Elston, husband an wife,
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements ,
.covenants , reservations and restrictions of record; ;
and will warrant and defend the same.
I
Dated this 21st day of December , 19_x,
a'=
- - (SEAL) Z (SEAL)
- — * /ee_ R. Elston
4
i --- (SEAL) f� Z-4 A�r/1 (SEAL)
* ---- s_ Clara L. Elston
i
AUTHENTICATION ,
} Signatures authenticated this 21St .ray of TATS OF WISCONSIN
_ � 19 ss.
County.
Per pally came before me, this day of
Charles E. White
the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
)UMXyXr,{X�,X��YYYXXXXX�X,+�YY+Y�YvYYYYYV VXXX
This instrument was drafted by
Charles E.• White, Attorney at Law to me known to be the person who executed the. fore-
going instrument and acknowledged t same.
River Falls , Wisconsin 54022
(Signatures may be authenticated or acknowledged. Both *� _
are not necessary.) Notar Co ty, Wis.
My C scion is permanent. (If not, atate expi ion
date:__ 19
*Names of persons signing in any capacity must be typed or prUited below their i,ires. , •�
WARRANTY DEED—STATE BAR OF WISCONSIN, FORM NO. 1--1977•
J
t
N
H
. Y
STC - 10.5 r
Y
SEPTIC 'TANK MAINTENANCE AGREA-MENT o
St . Croix County
• d
OWNER/BUYER Moser Homes , Inca M
ROUTE/BOX NUMBER 213 Locust St . Fire Number
CITY/^STATE Hudson , WI 54016 . Z1P
Lot 9 , ' West Grove Estates -�n
PROPERTY LOCATION : -,?w I&, S , Section 7 '1' 29 iI , R�
Town of Troy St . Croix County ,
Subdivision West Grove Est . Lot number_.
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Pruper maintenance cun-
sists of pumping out the septic tank every three years or sooner,
if needed , by a licensed septic tank Lm
_ Lr. What you put into
the system can affect the function of thu suIltic tank as a treat-
ment 'stage in the waste disposal system.
St . Croix County residents uia_X be eligible L receive a grant fur.
a maximum of 607 of the cost of replacement of . 4 failing system,
which was in operation prior to' July 1 ,. .-1978 .. St ....Cru,ix County
accepted this prugram, in ;August ,.o.f 1980, witli` the . requ.lrement that
uwners of all news stems agree to. keeli their systems properly
maintained.
The pr.uperty owner agrees to submit to St . Croix County Zouin.g a
certification form, signed by the owner and by a master plumber ,
journeyman plumber , restricted plumber ur 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 bf sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H O
J I/WE, the undersigned , have read the above requirements and agree N
to maintain the . private sewage disposal system in accordance with H
the* standards -set forth, herein, as- set by the Wisconsin Depart- ►d
ment• of Natural Resources . Certification form must be completed
and returned to the St . Croix County. Zoning Offk a within 30 days
of the three year expiration date. �`4'
S ICNEU
DATE
St . Cl>oix C:,unty Zoning Office
P. O. f-ox 98
Hammoid , WI 54015 1
715-7S 6-223[1 or 715-425-8363
Sign, date and return to above address .
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, G DIVISION ,BOX 76
LABOR AND' 'HUMAN ELATIONS PERCOLATION TESTS (115) MADISON W 53707
R
(H63.09(1)&Chapter 145.045)
LOCATION: SECTION: OWNS MUNICI ALITY: OT NO.:BLK. ]SUBDIVISION NAME:
/TQ9N/R 19E(or O I - Gravt_-Z'vA r&s
COUNT) ER'SBUYER'SNAME: MAALINGADDR SS:
,9/-CrOfy � 10605_L / d-'�1017
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAVDESCRIP TION: R I ItES RIPTIONSTERCOLA T TESTS:
,Residence �,// Vew ❑Replace �� 1.!f JZ /
RATING:S=Site suitable for system U=Site bnsuitable for system
NVENTIONAL: : IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
RRS ❑� IMN ❑� aS Vu aS ❑$ rev Ern ad
If Percolation Tests are NOT required DESIGN RATE:
9 If any portion of the tested area is in the 41A
under s.H63.09(5)(b),indicate: / lFloodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS 1
BORING TOTAL r'- DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH 4*. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 1 �° r� $. 7.2� >x.D sti
p
B-Z , v` 97y ' y �o� ir7+ S, . �3 a�/ 5. , s•+���54fr� �y2 `9"e
L .0.
?
A i a0 ��r.70�1cS���/ �H�CJ��/'�.1��/7GS�./7 BHCS�r
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V/_ /S ,t'rSe/sff�,I,z t'/3i,C_w",� 4,0 ;5r7C_Tvy,4
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PERCOLATION TESTS DaGSna7� '^ ��' fG•GJ,.
TEST DEPTH Y&WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER *14IMMS AFTE WELLING INTE=RVAL-MIN. PER OD 1 PERIOD 2 PERIOD PER INCH
P- i -��' p c 3
P P P_ � >r 3
P 4'1_" L G G <3
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.
p /
SYSTEM ELEVATION ! -�f y
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� _�.�__._ ' B i t
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(pring. / f �CE_IFICATIONKUMBEIR:ESTS WERE MPL TED ON:
L'Gt mod/ R lJe l� 2 ( �
ADDR S RT PHONE NUMBER(optional):
063W7
CST SIG
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
1
s - r
a - •
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test,your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
1 MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
6. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
?. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may he used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
. Complete all appropriate boxes as to dates, names,addresses,flood plain data, percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain,elevation)does riot apply, place N.A.in the appropriate box;
1 1. Sign the form and place your current address and your certification number;
12. Make legible 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 y
col) Cobble (3- 10") SS — Sandstone
gr Gravel (under 3") LS — Limestone
*s — Sand HGW — High Groundwater
cs Coarse Sand Perc - Percolation Rate
med s — Medium Sand W — Well
fs Fine Sand Bldg — Building
Is Loamy Sand > — Greater Than
sl - Sandy Loam < - Less Than
*1 — Loam Bn - Brown
*sil -- Silt Loam 81 - Black
si Silt Gy — Gray
*cl -- Clay Loam Y Yellow
scl Sandy Clay Loam R — Red
sic[ Silty Clay Loam mot — Mottles
sc' Sandy Clay Intl - with
sic - Silty Clay fff - few, fine, faint
c - Clay cc common, coarse
pi Peat mm — Many, medium,
rm— Muck d — distinct
p -- prominent
HWL — High water level,
Six general soil textures surface water
for liquid waste disposal BM — Bench Mark
VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit.The county or the Department rnay request
Verification of this soil test in the field prior to pert-nit 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 p ci-mit. The sanitary permit n;ust be obtained and posted prior to the start of any construction.
SS
P. B. L. 67 PLOTA N 0 E C T I 1\1
PROJECT ID L U M I
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N A M E Elo5 ZX- mK5 I q69
L 0 C AT 10 NJ__(�X uq L IC ENS E � 10, 9 ......
P T M A P
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FRESH A1' f*fH'1',,`.P_S AND OBSERVATION PIDE
CROSS SECTION
Approved Vent Cap
Minimum 12" Above 'Alf
Final G"Oe
4" Cast Iron
Above Pipes Vent Pipe
To Final Grade-'
Marsh Hay Or Synthetic Covering
Min. .2" Aggregli I
Over Pipe
Distribut Oil Tee
i24>_
Pipe
Aggregate Perforated Pipe Below
3, Beneath Pipe c. Coupling Terminating At
Oro Bot Lom of System