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Parcel #: 012-1016-00-000 02/13/2007 05:04 PM
PAGE 1 OF 1
Alt. Parcel#: 06.30.17.77B 012-TOWN OF ERIN PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
DONALD F&PATRICIA M KLEIN O-KLEIN, DONALD F&PATRICIA M
1579 CTY RD K
NEW RICHMOND WI 54017
Districts: SC =School SP=Special Property Address(es): "=Primary
Type Dist# Description " 1579 CTY RD K
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 4.607 Plat: 3544-CSM 13/3544
SEC 06 T30N R17W PT NE NE BEING LOT 1 Block/Condo Bldg: LOT 1
CSM 13/3544 4.607AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-30N-17W
Notes: Parcel History:
Date Doc# Vol/Page Type
06/09/1999 604608 1432/560 WD
07/23/1997 503/41
2007 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.607 51,400 280,000 331,400 NO
Totals for 2007:
General Property 4.607 51,400 280,000 331,400
Woodland 0.000 0 0
Totals for 2006:
General Property 4.607 51,400 280,000 331,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 519
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form - STC - 104
� a
AS BUILT SANITARY SYSTEM REPORT
OWNER _s�,, /iv�E TOWNSHIP zk,(Z) / ,Q/ SEC. <, T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
w j
Distances and dimensions to meet requirements of II. HR 83 �A 1ON�
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ��'T rp-i
/86� 0.
/w'// r
dv /fay
IT
391 4
0
- A-1 9 Af ?�
4\Olr/-?
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:_ Proposed slope at site: 8
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
i
Number of feet from nearest Road. Front'v 0 Side Rear,--0 feet
From nearest property line Front,0 Side 10 Rear,0 feet
Number of feet from: well building: L�Q
(Include this info r Lion of the above plot plan)( 2 reference dimensions to septa
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
q
Pump Model: Pump/Siphon Manufacturer: Pump Size
Y
' Elevation of inlet: Bottom of tank elevation:
ij
Pump off switch elevation: Gallons per cycle:
_a "
Alarm Manufacturer: Alarm Switch Type:
1 Number of feet from nearest property line: Front, O Side, O Rear, Ft.
Number of feet from well:
A
Number of feet from building:
(Include distances on plot plan).
!i SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: Length: Z,,2Z Number of Lines:_ Area Built:_
r`
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, Rear, Ft ` _
f Number of feet from well: �S
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:
/ Inspector•
Dated: �! Plumber on job: ��,�c� �W �s d�
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LAFLQR„&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
MADISON,
NE%, S6,T30N-R17W MCONVENTIONAL ❑ALTERNATIVE State Plan I.C.Number.
Town of Erin Prairie El Holding Tank ❑In-Ground Pressure F1 Mound I If
Count 'T'
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Warren Smallidge Route 3, New Richmond, WI 54017 )I-�f- n 4.l.UC�
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV..
Name of Plumber MP/MPRSW No.: County: Sanitary Permit Number:
Calvin Powers Jr. 1563 St. Croix 102787
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LAS L LOCKING COVER
PROVIDED. PROVIDED.
DYES ONO DYES ONO
BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING.(VENT TO FRESH INLET
ALARM FEET FROM LINE AIR
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. ILIOUIDCAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL FT R
PROVIDED.
OYES ❑NO ❑YES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE NLET
PUMP ON AND OFF) OYES 1-1 NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES DISTR PIPE SPACING MATERIAL' PIT INSIDE CIA tt PITS LIQUID
DEPT
DIMENSIONS
GRAVEL DEPTH FILL DEPTH UISTH PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO DISTR NUMBER OF PR OPERTV WELL BUILDING VENT TO FRESH
BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. PIPES FEET FROM LINE. AIR INLET
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.
1:1 YES ONO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WE LLS
OYES ONO El YES E:1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =PSOIL SODDED SEEDED MULCHED
CENTER. EDGES
1:1 YES ONO 1:1 YES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH NO.OF LATERAL SPACING 1GRAVELDEPTH BELOW PIPF FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLPMATERIALATNO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MAHKING
ELEV.. ELEV.: CIA.. ELEV.. PIPES CIAELEVATION AND
DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY ERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLAS
OYES ONO 1:1 YES NO
COMMENTS: PERMANENT MARKERS JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
❑YES 1:1 NO ❑YES ONO N �-sue
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE Zoning A
DILHR SBD 6710(R.01/82) 1 Idministrator I
SANITARY PERMIT APPLICATION COUNTY
T DILHR In accord with ILHR 83.05,Wis.Adm.Code
STATE SANITARY PER
MI #
Gay
—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 NO
PROPERTY OWNER PROPERTY LOCATION
h)�(4w -C,"_ 'I-, - 1,& '/a f_ %, S , N, R 7 E (Or
PROP RTY OWNER'S MAILING ADDRESS LOT NU BER BLOCK N14MBER SUBDIVISIO NAME
CITY,STA ZIP CODE PHONE NUMBER CITY NEAREST RQAA I K PR LANDMARK
❑ VILLAGE: J
II. TYPE OF BUILDING OR USE SERVED: - Tol X10 41— Qo_
Number of Bedrooms if 1 or 2 Family. OR ❑ Public(Specify): A/61
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. El New b.,.L l 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. X1 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:
(Ml tes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
^' Feet IIC�II Private ❑Joint ❑ Public
ypl
VI. TANK CAPACITY Site
in allons Total ##of Prefab. I:Plastic
Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel App
Tanks Tanks strutted
Septic Tank or Holding Tank — /
Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installationgLlhe private sewage system shown on the attached plans.
PlumbeZVs,.;/',J ame(Print): Plu is Sign ure:( o St ps) MP/MPRSW No.: Business Phone Number:
- f"''
Plum er's Add re (Street,Ci ,State,Zip Code): , Name of Designer:
VIII. SOIL TEST INFORMATION
Certi'ed i. Teste ST)Name CST##
I
_gAo —Ile
CST's ADDRESS(Street,City,SS e,Zip Code) Phone Number:
I COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuin Agent Signature(No Stamps)
.Approved ❑ Owner Given Initial ! rc arge Fee
1 /
Adverse Determination / �d r 66 ds.W !6
X. C MMENTS/REASONS FOR DISAPPROVAL: ls��
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;
Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in #1. Complete#2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in #1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given_when application is disapproved.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
---------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
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 GroundtBF
included the creation of surcharges (fees) for a number of regulated practices which Wjsco
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Tel sur
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
a
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in. full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property Section . T_,:�V _N-R 7 W
Township
Nailing Address
Address of Site ��
Subdivision Name
r
Lot Number
Previous Amer of Property J-21i
Total Size of Parcel !6e:j<'
Date Parcel was Created . f0?, 19 y 3
Are all corners and lot lines identifiable? �� Yes No
Is this property being developed for resale (spec house) ? Yes _ -4 _ No
Volume and Page Number -� as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
I
�� 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
T (we) CP t_U6y that aU sta.tement6 on thiA Ohm Me tAue to the best 06 my (0un)
hnowtedge; that 1 (we) am (ahe) the 0wneAk 06 the pnopeAty de�scAibed in thi,6
in6oimation 6o4m, by virtue o6 a waA.an.ty deed neconded in the 066.ice 06 the
Co" y RegtAt 06 Deedh ah Document No. ; and that I (we) pnehen,ffy
aun the pftoposed bite bon the Isewagne Po-5 eyes em (oh I (we) have obtained an
eahtmEnt, to nun with the above de c ibed pnopenty, bon the eondtnuction o6 6a,id
eyetem, and the came hae been duty %econded Xn the 066.tee 06 the County Regid.ten o6
Deede, ab Document No. ) .
SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
N
Parcel #: 012-1015-90-000 02/13/2007 05:08 PM
PAGE 1 OF 1
Alt. Parcel#: 06.30.17.77A 012-TOWN OF ERIN PRAIRIE
Current X ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O-HALLEEN, GARY&ARLENE&STEVEN S
GARY&ARLENE &STEVEN S HALLEEN
1580 TAMBERWOOD TR
WOODBURY MN 55125
Districts: SC =School SP=Special Property Address(es): *=Primary
Type Dist# Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 33.000 Plat: N/A-NOT AVAILABLE
SEC 06 T30N R17W 33A NE NE EXC COM NE Block/Condo Bldg:
COR,TH W 500'TO POB, W 820', S 750',
NELY 1111'TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
06-30N-17W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1171/39 WD
07/23/1997 990/118 QC
07/23/1997 4
07/23/1997 531/16
2007 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 05/31/2006
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 31.000 5,400 0 5,400 NO
UNDEVELOPED G5 2.000 200 0 200 NO
Totals for 2007:
General Property 33.000 5,600 0 5,600
Woodland 0.000 0 0
Totals for 2006:
General Property 33.000 5,600 0 5,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch#:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
IP
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
H
OWNER/BUYER
ROUTE/BOX NUM ER Fire Number
CITY/STATE ZIP S�
PROPERTY LOCATION : , _ , Section , T_CN , R 1-7_W,
Town of St . Croix County,
Subdivision Lot number
I
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 m_ y 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 wastewAtier 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 Co
three year expiration .
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth , herein , as set by the Wisconsin Depart- ►u
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 .
SIGNED 11
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 .
TI OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUS TRYY,,
INDUS C DIVISION BOX 76
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN,RELATIONS
(H63.09(1)& Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUN CIPALITY: LOT/N ]BLK.N .: SUBDIV[ ON NAME:IVY 4'/ �/a /T N/R E (o
COUNTY: OWN R'S BUYER'S, ME: MAI LI G ADDRE
USE DATES OBSERVATIONS MADE
5a Residence BEDRMS.: COMMERCI L DESCRIPTION: rr�� PROFILE DESCRIPTIONS PERCOLATION TESTS:
ieaResidence i� ❑New ZReplace
RATING:S=Site suitable for system U=Site unsuitable for system ]
CONVENTIONAL: MOUND: IN- PRESSURE:-PRESSURE: Q N-FILL OLDING TANK:REC MENDED SYSTEM (optiona1)
S ❑U N S ❑U S ❑U 19YSTEM-1
❑S U ❑J RA /�
If Percolation Tests are NOT required DESIGN RATE: If an
J y portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain, indicate Floodplain elevation:
C ,
PAIL, PROFILE DESCRIPTIONS
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER IDEPTH tk. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- - y -41
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER nNemi S I AFTERSWELLING INTERVAL-MIN. PERIODI PERIOD2 PERIOD PER INCH
P-
P- h5o AIZ u
P-J iv ;y, :J
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 /,'
.
3
l3
/ E 1
• ; t
t : _ sue
W '
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 COMPLETED ON:
AD R S: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST A RE:
i
h HTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
R-SBD-6395 (R.02/82) —OVER —
INSTRUCTIONS FOR COMPLETING FORM 115 - SEED - 6396 '
To be a complete anti accurate soil test,your report rraust 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 commercial use planned;
4. is this a new or replacement system;
, Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDINGS TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
S. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately lracating your test locations. Drawing to scale is preferred. A
separate Sheet may tar-; used if desired;
s. Make sure y<rur tsenchmark and vertical elevation reference point are clearly shown,and are permanent;
9, Complete all appropriate boxes as to dates,names,addresses, flood plain data, percolation test exemp-
tion if appropriate;
iii. If the inforn-tation (such as flood plain,elevation)does riot apply, place N,A,in the appropriate box;
11_ Sicn the form and plane your current address and your certification uUmber;
12. Make legible, copses and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LO AL AUTHORITY W11-HIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Snail Separates and Textures Other Symbols
st: -- Store falver 10") BR -- Bedrock
coo - C ;Petrie f3- 10") SS - Sandstone
gi &wvel (under S") LS - Limestone
sand 1-iGW High G3'c undv^..?atet
C;r3a3 s=:
S-,s'"rd Pe.ic P;r ;t l<itii?r Rate
llled:un)s.rr,d
t .ne Sand Bldg Bu id ng
Is Loamy::amts Greater TI-ran
Sandy Loam _ Less Than
_. Lr,arra Bn - Brov,,ii
`sil __ Silt LIlaw BI BIack
Silt Cry (1
l - i lay Loarr? Y
.,I Sanely C!a'Y Loam R -- Red
sic! Silly Clay !_Turn Tract - ttlsot11es
sc Sandy Clay lu - Imes,
- Si'•ty Clay fff ft ..�,fine,faint
Clay cc f",oron Cm% coarse
;,t - peat rnrn - N&,ny, medium
in .-- muck d - distinct
I-,) -- prorninent-
HWL - High +water level,
Six genera! soil Textures r;urfacc water
for lici ,id vvaste disposal BM - Bench Mark
VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary Iaermit. 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
swage system and a permit application must he submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit muo be obtained and posted prior to the start of any construction.
�of
PAGE OF
CU"US � •> LC � 1 V ('1 � r � 4JC1� J� S ��r't'�
Fresh Air Well; And Observation Pipe
( Approved Vent Cap
Minimum 12"Above
Final Grade
20-42"Above Pipe _4"Coat Iron
To Final Grade Vent Pipe
Marsh Hoy Or SynthetlC Covering
win 2"Aggregate
Over Pipe Olalribullon —Tee
i Pipe - 0 0 0 0
6"Aggregate a Perforated Pipe Below
Beneath Plpe
o —Coupling Terminating At
Bottom Of Syalelll
v.o..�
SOIL FILL
DISTRIBUT101.1 PIPE ��NTN
APPROVED ETIC COVER
0 "MATERIAL- OR 9" OF STRAW
OF AGGREGATE —�� OR (MARSH I-IAy
toy OF iZ -zi/2 AGGREGATE
'CLEV. oF� FEET
DIS-rRIP_UTION PIPE TO BE AT LEAST t_7� 1JCHES BELOW ORIGIAIAL GRADE
A►JU AT LEAST20 IUCHES BUT NO MORE THAIJ H2 INCHES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXCAVATiop F•RoM oKitwA.L 6RAIDr- WILL BE IMCHES
MINIMUM ®Eprh of E'ACAVATIOM MOM. OlkI6IWAL GR49€ WILL BE I►vcNEs
SIGHED:
LICENSE NUMBER: 40 V
DATE
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