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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Senn s TOWNSHIP al ign SEC. .25 T Z9 N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
Ll�oo�v.�e
SUBDIVISION AI LOT /V49 LOT SIZE AI-A _
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used y o* 'Wef/�psjj?q
i
Elevation of vertical reference point: /0010 Proposed slope at site:
SEPTIC TANK: Manufacturer: ZtA_e 7�S Liquid Capacity: /000 qp�,
i
Number of rings used: �GVp Tank manhole cover elevation:
Tank Inlet Elevation:_�,2rl Tank Outlet Elevation: 97. 93
Number of feet from nearest Road: Front,O Side Rear, O 2-70 feet
From nearest property line Front 10 Side,ORear,2 Z/Z� 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
1
Manufacturer: Liqirid Capacity:,
Pump Model: Pump/Siphon ufactVe: 6rer: . Pump Size
Elevation of inlet: o tank vation:
Pump off switch elevation: lon r cycle:
Alarm Manufacturer: rm wi h Type:
Number of feet from nearest p operty ron O Side, O Re ar,0 Ft.
Number of f t from
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: /Z0 Length: Number of Lines: Z Area Built: �Z`l G
Fill depth to top of pipe: ,200
Number of .feet from nearest property line: Front, O Side,0 Rear,O Ft .,22
Number of feet from well: 115 9
Number of feet from building: 225
(krjalued distances on plot plan).
SEEPAGE PIT'', rt
Size: Number of pits: Y i Dia ter:
Liquid depth: Bottom /-Je/ge pi/levation:
Area Built:
Has either a drop box O or distrib ion x O een sed on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacit
Number of rings used: eva on of om of tank:
Elevation of inlet:
Number of feet from nearest ope line: ront, O OFt.
Side, O Rear,
Number of feet from w
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector•
Plumber on job:
Dated:
License Number: 1$4 &/ Z 9
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7..969 BUREAU OF PLUMBING
MADISON,WI 53707
SWa,SW1,4,S25,T29N-R16W NY CONVENTIONAL 1:1 ALTERNATIVE Slfate Plan I.D.Number:
} Town of Baldwin El Holding Tank El In-Ground Pressure F-1 mound
1 HWY 12
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Dennis H. Gunderson 443 Oak Street, Woodville, WI 54028 1_ 9 _?7
:dam
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.. Coun y. Sanitary Permit Number:
Dale E. Hudson I6629 St. Croix 95974
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY TANK INLET ELEV.: TANK OUTLET ELEV.: IWARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
U V OYES ONO ❑YES ❑NO
BEDDING: VENT DA.. VENT MATL: NIGH WATER (' ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET'.
❑YES ONO ❑YES ❑NO NEAREST'
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ❑NO ❑YES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. N0I:R OP PROPERTY WELL. BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEARIWST'
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing _EIVGTH ojAMETER MATERIAL AND MARKING
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:
a g� °WIDTH. LENGTH. JN!E�0 F DISTR.PIPE SPACING. COVER INSIDE CIA.. #PITS. LIQUID
TNCHES MATERIAL' PIT DEPTH:
111r ;z S 2
GRAVEL DEPTH FILL DE PTH IDISTR.,PI PDIPIPE DISTR.PIPE MATERIAL: NO DISTR 0 MS ,R F 'r PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. NLET ELEV.END. PIPES. IFr;�T ,FROM LINE: AIR INLET:
111�ARE�T FY!
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES 1:1 NO
SOIL COVER ITEXTURE, JPERMANrNT MARKERS: OBSERVATION WELLS.
El YES El NO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOI L. SODDED-. SEEDED. MULCHED:
CENTER. EDGES.
DYES 1-1 NO ❑YES ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER.
' �.��k TRENCHES:
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO-DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEV.: ELEV: DIA.: ELEV.: PIPES. DIA.:
"VAS ANM
Ito
HOLE SIZE HOLE SPACING: DRILLED CORRECTLY_ COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS,
' l
YES NO
❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NER �'PROPERTY WELL: BUILDING:
` LINE:
DYES ❑NO 0 : YES ❑NO N � T�,�
�.d
6
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE:
Zoning Administrator
DILHR SBD 6710(R.01/82)
SANITARY PERMIT APPLICATION COUNTY
51LHFR In accord with ILHR 83.05,Wis.Adm.Code S/ ` O
STATkSANITARY PERMIT#
—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 OYES I NO
PROPERTY OWNER PROPERTY LOCATION /
S&)%,_5-U)'/a, S ,Z5 T 9, N, R �op It(or)W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
a ...7�i �A[//
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
i ❑ VILLAGE *3GlJO�
l� a•/i' l
v, m2_f IV TOWN OF
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): AIX
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. A 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.X Conventional b. ❑Alternative c. ❑ Experimental
2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. X seepage 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): /� L/
/ 7 7. '4 Feet Private El Joint ❑ Public
CAPACITY
VI. TANK Site
in allons Total ##of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 44 /��d ❑ ❑ ❑❑ Li 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 Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
�De?le_ Wmq_1ro,,e1- � azz 4;<zq? 1 (
Plumber's Address(Street,City,State,Zip Code): , > Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST## ��/3
4/e Z. u�so
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
o
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issui Agent Signature(No Stamps
Approved ❑ Owner Given Initial S charge Free` —
Adverse Determination R� -lXJ ?
X. COMMENTS/REASONS FOR DISAPPROVAL:
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;
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/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'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
------------------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
common!y 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 Ater
included the creation of surcharges (`ees) for a number o regulaled practices which Wiscolzi s
can„effect groundwater. The surcharce took effect on July 1. 1984. All of the water that buried reasllt'8
is used in your building is returned t� the groundwater th-ough your soil absorption o
system or the disposal site used by your holding tank pumper.
. a
The monies collected through these surcharges are credi?ed to the groundwater fund adminis-
iere:? by the Department of Natural Resources. These funds are used for monitoring ground- t
W-I,e , gr:,unrlwater contamination irvestigations and est-:51ishment of standards Groundwat- ,
s v:r,rth protecting.
r;- =98 R o3,MJI
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 JD,r��s. u�C ���/,,�
Location of Property (. It 14, Section , T ` N - R W
Township4� ��i
Mailing Address '7'`-�
Subdivision Name
Lot Number A
Previous Owner of Property �CG'bb _ G �jid' r�ySd
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 1� No
Volume and Page Number �'3 Z as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION 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) eeXU6y that a.tt 6tatement6 on thiA 6OU an.e tn.ue to the beat o6 my (oun)
know-tedge; that I (we) am (cute) the owneA(a) o6 the pnopeAty de,&cAibed in thin
.i.n6onm t.ion 6oAm, by vZ tue o6 a waAAI-aanty deed AeeaAd d ' the O66.ice o6 the
.County Regiateh. o6 Deeda a,s Document No. �/' ; and that I (we)
pnea ent.Cy own the P.Aopoa ed a.c to bon the a ewage di6Po,6FLFAy,6tem (on I (we) have
obtained an easement, to nun with the above de cAibed pAopenty, bon the
conatAucti.on o6 6a.id Ayatem, and the dame has been duty Aeconded in the 066ice
o6 the County RegiAteA 06 Deeda, as Document No. ) ,
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
r
DATE SIGNED DATE SIGNED
WARRANTY DEED 1 .
'1wATE BAR OF,WISCONSIN TOIi>![ =:
erson
,�. .. ................................... :
""'.. p.enni.s H. Gunderson. and_.
t Y
x
ivans3e>;son., husk�and..an-d-wife,..............
a . ........... ..... ..............
``4...........................................................
..........................................
t
' r St...Croix .. .............
I'll to l estate in ... ..... ..... ................. .County,
,rte
2) ,rods of Southwest Quarte .
Quarter (SW-1/4 of SW-1/4) of" ¢s
enty-five (25) , Township Twenty nine ,
ange Sixteen (16) West. `
i
� Y
4
h q
t
✓�' " . homestead property.
'arralltleb. .
y*
xr r
a .,. day of .. .........J1iLle...
nder`son •
t.
,r
...........(SEAL) t"
......... ' a•�k
NOW-
MN TICATION A -3DGM3N.
)o I Anderson STATE OF WISCONSIN
... ..................................
i
r, ... St.:..GrQ .: County
day of ...... .. . ............ 19...... Personally came ybefore..me"tQhis
r
...........YL121@ .L ..L98wY �'
......Elwood—BA—An arfia
t TE BAit OF WISCONSIN
08Wia Stets.j to me known to,betrtlep rho
foregoing
pAFTED by
3kow S C ...........
...
M4 0e • .......Lest
Notary Public,
b csted'oY cknowledged. Both My Commibbiclt,
date: ..
e(ty 3honid ba typal or printed below their ti`naturm 2
STATIC BAR OF WISCONSIN ,
FORM No. b—IV82
Y
�wa
h.
10
ST . CROIX COUNTY ABSTRACT COMPANY
HUDSON, WISCONSIN
CONTINUATION OF ABSTRACT NO. 18,035
From the 15th day of May , 19_B5_at 8*00 o'clock in the A. M.
of the land described as:
E 12 rods of SW'l4 of SW'/4 of Section 25-29-16.
11
County Clerk of St. Croix County, Tax Deed.
Dated June 27, 1985.
-to- Ack. June 27, 1985.
Rec. June 27, 1985.
County of St. Croix. In "715", page 195, #403083.
Baldwin, Olga Hagen, Parcel #378 A; E 6/40 of S.W.-S.W. ; Sec. 25-29-16.
Recites: This is a replacement Tax Deed for the original Tax Deed issued from
the County Clerk's office on March 25, 1970. Fee #4 Exempt.
12
Elwood E. Anderson, Affidavit.
Dated June 28, 1985.
-to- Ack. June 28, 1985.
Rec. July 3, 1985.
The Public. In "715", page 431 , #403215.
Elwood E. Anderson,: being first duly sworn on oath deposes and says: 1. I am
the Elwood E. Anderson ';that is named in the Quit Claim Deed from St. Croix County
to myself recorded on July 16, 1970. I have been open, notorious and hostile poss-
ession of the property described as the E 6/40 of the Southwest '/4 of the Southwest
'/4, Section 25-29-16, since July 16, 1970.
13
Elwood E. Anderson, Warranty Deed.
Dated June 28, 1985.
-to- Ack. June 28, 1985.
_ec ,
Dennis H. Gunderson and Bonnie K. In "715", page 432, #403216.
Gunderson, husband and wife.
E 12 rods of SW 114 of SW'/4 of Section 25-29-16.
Recites: This is not homestead property. (Transfer fee $30.00).
1 0 z
16 ®C ulliz ova "7 i 5
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N 5��
ST . CROIX COUNTY ABSTRACT COMPANY
CONTINUATION OF ABSTRACT
H
a
S T C - 105 rr-
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
r
OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
CITY/STATE GC/eXj�!/s C�C/i 'LIP
PROPERTY LOCATION: SV 14, S� 14, Section Zs T �_V N , R W,
J I
Town of St . Croix County ,
Subdivision 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. H
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein , as set by the Wisconsin Depart- v
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 .
S I C N E D
DATE S ��2-1
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 .
DEPARTMENYOF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, GG DIVISION BOX LABOR
HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON W 53707
(H63.090)& Chapter 145.045)
LOCAT ION:e- SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
SW a , 5- /T29N/RIGS(or W 1�alolw,',�
COUNTY:f0/�,( O�ER'S BUYER'S NAME: e�SD� MAILING Al aRESS:c � / �•
USE J DATES OBSERVAT NS MADE
NO.BEDR77MERCIAL DESCRIPTION: I PROFILE DESCRIPTIONS: PERCOLATION TESTS
:
,XResidence New ❑Replace 5 _ 29_t?-7� O�
RATING:S-Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND:, IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
S ❑U ®S ❑U ®S ❑U ❑S (ZU ❑S ®U earl
If Percolation Testsare NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: /V I Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTHiZ. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- l .33 40 , Alo n > 7,33 13-Wls-,�
B- z �'-OS /d/ o �'Ocp 1l> 'B ' ° /�'' '�• /,Z''Bn - 58" �eo1S
B-3 �-o' /00, e �'� I7 1s-,/ , 9'' s�' �" B me
B-4 61.25 9�,�9� Alo ny 6,25� Y/'; s ' ! a''' nee
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER -i N 61•iES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P E R 170 PER INCH
P- lo 3 3 3 ,3
P- 0 3''
P- 3•
P-._.
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference 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 97,Y/ _
¢m T-rt— -
r
TN
LE I I I
I
__ ..-......... .___.
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(print): TESTS WERE COMPLETED ON:
'Da le
ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional):
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CST SIG ATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
s
I INSTRUCTIONS FOR COMPLETING FORM 115- SBD -6395 '
;To kie a complete and accurate sail test,your report must include:
1. Complete legal description;
2. The'use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or cormnerciai use planners;
4. I '' liti"a'new or replacement systerrr;
5., Complete the suitability rating boxes. A SIT,' IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown hi�i <,r wi iri!iy w-,file descriptions and completing the plot plan;
7. MAKE, A LEGIBLE diagram accurately loc,&ng your TE;st locations. Drawing to scale,is preferred. A
separatesheet may be used if desired;
8. Make sure your benchmark and vertical clevation i elerence point are clearly shown,and are permanent;
9. Complete all appropriate boxes as to dates, names,addresses,flood plain data, percolationtest'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 farm and place your current address and your certification number;
12-Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED.'WITH THEv'
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS F01'3 C"ERT!FIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob -- Cobble (3- 10") SS - Sandstone
_ g r.— Gravel-{under 3" - rm
estone
s. Sand HGW - Hi g h
Groundwater
_ cs -- Coarse Sand Perc - Percolation Rate
med's"- Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is - Loamy Sarni ; Greater Than
*sl - Sandy Loam < Less Than
*1 - Loam Rn - Brown
*sil - Silt Loarn BI Black
Si Silt Gy Gray
*cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R -- Red
sicl - Silty Clay Loarn mot - Mottles
sc -- Sandy Clay w/ with
sic - Silty Clay fff few, Pine,faint
*c - Clay cc; - common, coarse
pt - Peat it rn - Many, medium
m - Muck d - distinct
p - prominent
> 1-IINL - High water level,
* Six general soil textures surface water
for liquid waste disposal 'Pr1 - Bench Mark
VP --- Vertical Reference Point
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 r•e subrnitted to the appropriate local authority in order to
obtain`a permit. The sanitary permit must be �i ,Oi posted prior to the start of any construction.
-
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
796-2239 (HAMMOND)
1 _
R 19 19 M 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
November 19, 1987
Mr. Dale E. Hudson
Boldt's Plumbing & Heating
820 Main Street
Baldwin, WI 54002
Dear Dale:
Please submit an as-built to this office for Dennis H. Gunderson Located
in the SW-4 of th ESWI4 of Section 25, T29N-R16W, Town of Baldwin.
If you should have any questions regarding this matter, feel free to
give this office a call.
Sincerely,
� �/�
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Roxann Croes
Administrative Secretary