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Form - STC - 104
TA AS BUILT SANITARY SYSTEM REPORT
OWNER B 1 d' cowme. TOWNSHIP 2o SEC. T a? N-R nw
m J CJI,GIB
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION V I OV QK 'StA 10 N LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
1
3 BUR00 P1 i,
ROME
o 1 DLC)Q-
0 9
N 'BED
� d �
' y
1 1 1
N
NCB ORTH ARROW
BENCHMARK: Describe the vertical reference point used X of W 0O
h 0
Elevation of vertical reference point: _V I - Proposed slope at site:
SEPTIC TANK: Manufacturer: W e-e Liquid Capacity: 10100
'
Number of rings used: I - I Tank manhole cover elevation: 01- 62
Tank Inlet Elevation: 99, 'S Tank Outlet Elevation: T8, 73
Number of feet from nearest Road: Front,O Side, Rear, O �11Q feet
From nearest-property line Front 10 Side,O Rear, feet
Number of feet from: well d ^, building:
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
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, Ft.
Number of feet from well:
Number of feet from building::}. q p
(Include distances on plot plan). 5ko1 ti �� NeppeR : Q11�g
SOIL ABSORPTION SYSTEM I$ `ND 77 U,-17
9 c.
`1 0
Bed: I/ Trench: q A 646M eel
Width: +;�, Length: Number of Lines:_ Area Built:. 5
ya„
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,Ft .
Number of feet from well: FIt
Number of feet from building: (p'
(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:
Q Inspector: _041s xyj'�w
-- - '6��
Dated: Se- 1 188 Plumber on job:
License Number: TPF,5 0 3�0
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HtJMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.D.BOX, 1939 BUREAU OF PLUMBING
MADISON, ,S16,WI 53707
NW T28N-R19W 'CONVENTIONAL El State Plan I.D.Number:
�,NE% )If assigned)
Town of Troy ❑Holding Tank ❑ In-Ground Pressure ❑Mound
Lot 16 Glover Station
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIOPIDAZTE
Bill & Connie Milder 369 South Pacific Road, Hudson, WI 54016 R a 1 'y
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.
S4.)
Name of Plumber: JMP/MPRSW No.: County: Sanitary Permit Number:
Richard Hopkins 1059 St. Croix 112672
SEPTIC TANK/HOLDING TANK:
MANUFA TUBER: LIQUID CAPACITY. TANK INLET ELEV.: I TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROV ED. PROVIDED'.
S f � UO 9 11� YES 1:1 NO DYES NO
BE ING: VENT IA. VENT MATJJJ,,,... HIGH WATERljI3,�� " ROAD: PROPER WELL: BUILDING:�VE T FRESH
I /L / ALARM: OM ( LINE: r l� AIR INLET:
DYES N�NO L!'-� ❑YES NO 1�#EARST"W"1 I l 5
DOSING AMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ❑NO A DYES ❑NO I ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTRO S JERfXAOL f4t MBC"1ai 01~ PROPERTY WELL: BUILDINGVENT TO FRESH
INE(DIFFERENCE BETWEEN PUMP ON AND OFF) ❑Y N 11F11tREST;
SOIL ABSORPTION SYSTEM.Check the soil moisture at the de o PI W g LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction s all ase until '
the soil is dry enough to continue.) 1!} l(�1
CONVENTIONAL SYSTEM:
�y WIDTH: LENGTH. NO.OF JDISTR.PIPE SPACING: C VER ]INSIDE DIA.. #PITS. LIQUID
TRENCHES. M ERIAL: PIT,. DEPTH_,-
MENS1 S
GRAVEL DEPTH FILL DEPTH DISTR.PIP DISTR.PIPE DISTR.PIPE MATERIAL: NO DI EK OF PROPERTY WELL: BUILDING: VENT LE FRESH
BELOW PIPES. ABOVE COV ER. ELEV.INLET.ELEV.END. PIP LINE AIR INLET:
I %k q ��� �I�ti �� a� NfAR'EST
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 1:1 NO
SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS
1:1 YES ❑NO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH O:FTOPSOIL SODDED. SEEDED: MULCHED.
CENTER: EDGES:
DYES 0 N DYES ONO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
S WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
_ 9 MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
ELEV.:
ELEV.: DIA.. ELEV: PIPES: DIA.:
ON AIN
HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
'M PLANS:
❑YES NO
❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: r` PROPERTV WELL: BUILDING:
COMMENTS. LINE:
DYES
El ❑YES 1:1 NO
�f0
Sketch System on Retain in county file for audit.
Reverse Side. sICNAT TITLE:
DILHR SBD 6710(R.01/82)
�ILHR SANITARY PERMIT APPLICATION COUNJY '
In accord with ILHR 83.05,Wis.Adm.Code STATE?A�TARY PE GRMIT#
l ID 7,R
—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 jFi�f7NJJI NO
P P TY OW R PROP RTY OCATION
Dill * -0 aN 10, P1 I N t/a '/4, S TJ , N, R 11 E(or)a
PROPER Y OWNER'S AILIN DDRE LOT NUMBER BLOCK NUMBER SUB IVISION NAM
CITY,qTATE a ZIP CODE PHONE NUMBER CITY NEAR ST ROAD, KE O LANDMARK
Sd N + C•C� O VILLAGE . I � D TOXXW
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family. OR ❑ Public(Specify): d tj .Q K V') j H E
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. N-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 Tan k
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 25 See a e Bed b. ❑Seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minuigs per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): _
V6 Feet ®Private ❑Joint ❑ Public
VI. TANK CAPACITY in gallons Total ##of Manufacturer's Name Con- Steel Plastic Prefab. Site Fiber- Exper.
INFORMATION New xisting Gallons Tanks Concrete glass pp.
Tanks Tanks structed A
Septic Tank or Holding Tank Q�Q
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): Plu s Si nature:( Stamps) MP/MPRSW No.: Business Phone Number:
R,AP,-KA P.,Kw, � //1 ) 9 /5 90)o
Plu er's Address(St eet,Cit ,Slate,Zip od N of signer:
Kt ) L or J c- �' o c� d Ki►�
VIII. SOIL TEST INFORMATION
Ce 'fied S 'I Tester(CST)Name CST#
. e e Flo,
CST's ADDRESS(Street,City,State,Zip Co ) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial Su harge Fee''
Adverse Determination �V. UV
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03 186) 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. Agnew permit may be needed
if there is a change in your building plans, system Ideation, 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 properlyt 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. Th
P P P ty e
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 i - -
commonly known as the groundwater protection Jaw. This change in statutes was the
result of over-2.years of s#eady negotiation and public debate..The groundwater bill Grourtcl
included the creation of surcharges (fees) for a number of regulated practices which Wisco in�S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried res+�rD
is used in your building is returned to the groundwater through your soil absorption
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 - X100. ,
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 intendedfor resale by owner/contractor, ("spec
house") , then a second form should be retained.'i d completed "when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property Bill and Connie Milder
Location of Property NW ;4 NE ' , Section 16 , T28 N-R 19 W
Township TROY
Mailing Address
1106 Crestview Drive
Hudson, Wisconsin • 54016'';
Address of Site 369 South Pacifit Road
Hudson, Wisconsin "546141-'1
Subdivision Name GLOVER STATION
Lot Number 16
Previous Owner of Property C.M. Bye and Dennis R. Schultz
Total Size of Parcel 2.01 Acres
Date Parcel was Created September 11 , 1979
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes X No
Volume 811 and Page Number 419 as recorded with the Register of Deeds.
s '
INCLUDE WITH THIS APPLICATION THE FOLLOWING: i
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 Sur-Vey Map shall also be required.
PROPERTY OWNER CERTIFICATION
1 ((Ve) eeAti.6y that att statements on Vv, 6onm ane �&ue a he..beAt 06 my (oun)
knowledge; that I (we) am (one) the owneA(.$) o6 the pnopenty ducAi.bed in this
.in6okmat.ion 6o4m, by viAtue o6 a waAAanty deed neeonded in the 06 fi-iee o6 the
County RegisteA o6 Oeed6 as Ooeument No. 437607 and that I (We) pAuentCy
own the proposed ad to bon the 6ewage dispod ays em (on I (we) have obtained an
e"ement, to nun with the above de cA bed pnopehty, bon the conatnucti.on o6 said
.syatem, and the dame has been duty neeonded in the 066.iee o6 the County Regi.ateA 06
Dee a6,DocUM7 No. 437607 ►,
S GNATURE OIL OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 1888 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
437601 BOOK 811 REGISTER'S OFFICE
This Deed made between ___- and---------------------------- ST. CROIX CO., WI
Dennis R. Schwa Z.-as__tenants in common...... ...... . ......_-•---- Recd for Record
------------------------------------------- ------------------ Grantor, MAY f 31988
- --- -- --- ---
and_._William-P.--Milder- and Connie A. Milder- husband and - of 11 :40 AM
wife, as marital survivorship property,--------------------------------
----------
-------- ----------- - --------------
------- -- - ------ ---------• ------- ------------------------------------------------, Grantee, Register of Deeds
Witnesseth, That the said Grantor, for a valuable consideration_.__..
----
conveys to Grantee the following described real estate in------_S___t__. C roix RETURN TOWm P. Milder
-__-. --.
903 S. Croix Street, No.
County, State of Wisconsin:
Hudson,
Tax Parcel No: -----------------------------------
Lot 416, Glover Station Subdivision, located in the NW,-4 and NE-, of Section 169
Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin.
S £ O
This -----is not homestead property.
x ; (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
rantors
And g - --•--- ----- -
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
for easements, covenants, and restrictions of record
and will warrant and defend the same.
11th April 19.88-
Dated this --------------- day of ---------- --- --------------
---------- -----(SEAL)
-------------- ----- -(SEAL) --��---- ----`- �'-- - -
—
* CA M &sin -...
(SEAL) -uw.o -
---(SEAL)
Dennis R. Schultz
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
----- ss.
------------------------ ------ ---------------------------------------t. Croix County.
-----------April---- ----------, 19__V$.. the above named
-- -------------------•--------------------------------------------------------
* ---------------- -------------------------------------------------------- - ----------------------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
-----------Dennts•A,...Schultz-----------------------------------
(If not- ---------------------- ------------------------------- ----- ----------------------------------------------------------------•---------------
authorized by § 706.06, Wis. Stats.) to me known to,W the person -.s-------- who executed the
foregoi inst6ment and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
M' Bye- Attorney at Law � �Q
- ---------- -------
P. 0. Box 167, River Falls, WI 54022 *---Dianne Qy-------------------------------------------
---------------- ---•--------------------- - -._ .._..--- •- ----•--- Notary public.._------5a.•_Cx91.x----•--•••--••.County, Wis.
My GomiKi i pe�lnanent.(If not, state expiration
(Signatures may be authenticated or acknowledged. Both �°e�1 Ei
are not necessary.) date: -
¢ .N aE�t{[ber 6 19 R8 )
.
:.•
*Names of persons signing in any capacity should be typed or printed below their signatures.
STATE BAR OF 'T13CCNSIN
KeMinefcoornp"Eq FORM No. I—'1992 Stock Rio. 1 3001
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Bill and Connie Milder SSaamm
ROUTE/BOX NUMBER 369 South Pacific Road FIRE NO. Aaaress
CITY/STATE Hudson, Wisconsin ZIP 54016
PROPERTY LOCATION: NW 1/4 NE 1/4, Section 16 , T28 N, R 19 W,
Town of Troy , St. Croix County,
Subdivision Glover Station , Lot No. 16
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
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must' be completed and returned to the St.Cro' County Zpfing Office within
30 days of the three year expiration date.
SIGNED
DATE k4
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
s r x
GLOVER STATION
LOCATED 1N THE NW/4,AND THE NEI/40FS8MMl6T28N,RWK
TOWN OF T 10Y.ST-CRM CU NTY,WASCONSIN
LADSrt3 fRj;ii2 FALLS*
S'c HOC)C.S Low" aarw
.aw
R A/MM1 t Y '�_.,,.,a YIp,lIIEY LNdf r/ • at
SOLI) 01A 10
pea .ewes .as .pan so.. � :ar
SOL ,...
SOLD.
I r ._.�
SOLD'e` �•, SOLD
SOLD '100 SAIr.� I -- \ �
! SOLD S
.owJ .mar_L_ T
Tr-- --- : S♦ x.�. 1`��. _ _
, • D
\SOLD `l$. L >o OL
4� SOLD
g 123*0 .' `�.23}g00
! .•�..yC ,��; ;;,� SOLD x S � SOLD
YSOLD
xae s.u.r a,auax•e.s
r6v.a�'b. .rwssi.�i.ir eaves M .a
sacs
.a.as r.srawr: x w,...u�'.o•tl1°.�••';••.••r w: �"a'x r�'a w�o�w.�ruw.�ie..y
ro srso uw suivxmr
- nvxa rus�w swxe /Qr/"r ��-di
m.. n.n wsr.wev w onsrrm a. — sxEn i e a san
I
C
UL-NAK I NILIN I ter KLVUK I UIV JUIL DVnIlIkI Mlr V DIVISION
INDUS PERCOLATION TESTS (115) MADISON WI 53707
L. .l AND
HUMAN RELATIONS (1-163.090)& Chapter 145.045)
-----
LOCtA ION: SECTION- TOWNSH UNICIPALITY: OT OT NO.: SUBDIVISION NAME:
st �/ 16 Tz8N/R )9E (cr
-t-r�u y �-t�+`�uN
COUNTY: WNEFr BU ER'S NAME: MAILIN AD D SS: Lj Z) �iP'(-N U
ST'•Ci�itx �E��.t�. wOKt'.1'C' �► v�'�. ,� LL� w1 S ozZ
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMER IALDESCRIPTION: PRO L IP NCT�ESTS:
Residence 3 1�• New �DR-pl-ce S_ U 8`7 _ 5- p
RATING:S-Site suitable for system U-Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND PRESSURE:r)''!31 EM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional)
®S ❑U QS ❑U ®S ❑U 10S ❑U ❑S FWU
If Percolation Tests are NOT required an
DESIGN RATE: If is in the
I y portion of the tested area N.A
under s.H63.09(5)(b),indicate: C L tics J Z Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-iN=E—S CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH If{;ELEVATION OBSERVED EST.HI TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 1 10.0' 101.y ' tivo� L � I o •o _
�•-) ' U\C1gn LTS j 1. U.Q ' 1�n 1S1
B- Z 01 101.Z t.�oyJ C 7 9 3 6•-7' �t
o.`� ' bk�h LTs ;o_S'8n 5 ; \•v' t3►� is ;
B- 3 10.3 \b"L.ol tvo�JE 7 10.3 �. I ' t_t B S
t0 Z 1 p.$' �k E3� L TS ; o•� r Bn L ; l.2 '$n lj;
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WA ER L V L IN HES RATE MINUTES
NUMBER ttdC11E9 AFTER SWELLING INTERVAL-MIN. p p PER INCH E�
P.P_ Z y,9 , O \� 3/ 3/ 1 3l Sr 6 ►ul.b'
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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 percen
of land slope. IIJlTlPfLd1 �-'CI��t=`Mc�
SYSTEM ELEVATION �L• 9 6.�
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1, the undersigned,hereby certify that the soil tests reported on this form wale III by rion' a6cord with th procedures and methods specified in the Wisconsi,
Administrative Code,and that the data recorded and the location of the tests are cgrrect to tIM.yK%Jof my kn ledge and belief.
NAME(print): S WERE COMPLETED ON:
ADDRESS: VT ERL)X -`2..6 CERTIFICATION NUMBER: PHONE NUMBER(optional)
LL I Su�1J S-7!z, 71S_�?S- ulijy.
CST SIGNATyJIRE:
Y�
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
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FRESH All: ItILI.:'PS�AND OBSERVAT.10tl PI.QE
CP
.nSS SECTION
(-7) Approves] Vent Cap
Minimum 12" Above t
rinal G�acl _.�__. ItdW� � :•�►':.
T MAY 4" Cast Iron
Above Pipe Vent Pipe
To Final Gracie--,--
Marsh Hay Or Synthetic Cover- i ng
Min. 2" Agg oy',l I
Over Pipe � (�--
Distri.buti- �� -o �— — Tee
Pipe
Aggregate Perforated Pipe Below
ND(� 13cricath Pipe c._ _—Coupling Terminating At
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Bo t t-om o f. System