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HomeMy WebLinkAbout018-1049-00-000 C1 cn p C f7 d r1 I c `-° o `D— c m r: o 3 0 = N Z O N O y N• ? 3 O C f O (= IV FBI j A z a m N ? 3 `co CD CC O A R O l 4 o C = (D n m o D o ° ^' 3 5y w ! S c ra v u> CD m an (o fD y N a C 9 = c = c CL N 3 O ^ A A A O L d l�CD A CD CO w = N 0 c cr 3 3 a o 0 0 0 = tl�ll PL � c ca ca ca �4 N -- Q v v Oo ° =v d o o ' CL N I z z l� ° z D m O o"i O = 0' CD ? m • cn m c CD CD m=. c w a CD ZCD ` N = p Z ID �i CL A O z N N v T 10 I a 3 z °o fT z I v a w m I � a 3 CD I m c o a CD N I I y I I p n I � c I f�0 ti yV I c I °a I ti o O < N 0:)ffl O v Op � TA O O O ti 0 69 h ti d a tl O Q a 0 M I HO ° C v0 m N t0 V3 Ol 0 O O C W O c p I N w Y fC Y Ol x 00-- O O T N O L O = C 'C Z C 7 (0 CO C N LL C 0 O 3 � 4) ;6 j aEi ¢ � I O M CL Z a' E O rn3 am ar N H CN Z I _O Z c � w I I 4) N a O m 0 O O O • N L L EL C C Q t�.l � N O 0 Q v- Z H Z O Z O N _ w M z N J 01 � Lo LO a u�i a i .r 0 G C a a `�lJ ! Z ; x333 IL 0) • o ° aaa IL 00 CO ) O N = O O 0 1 fq J U ', � rn _rn � (D "0 O O _O N _M O N 4 0 0 0 0 0 0 U = N N N N N O O '0 co ^ ` ml N a z U.) 0 O U) N w? U V C C O 10 ' O 9 Q O « U d j 0 0 rl- O M — f0 U .+ 0 l4 N C C W O > rn o 0 0 0 0 _N w I� CO C N N C O r \ M OS C � Z Z w 'O V O r te•- ~ W N E C 0 a0+ 7 E E '� t O cn •� O N = J N O Z y H H g fn O r v V� .Q € a E L a CL 'v _1 A cia o o 0. iv PUMP CHAMBER Q Manufacturer: j cj Liquid Capacity: 1 Pump Model: W�-©:3 Pump/Siphon Manufacturer: �.,� _ Pump Size 1 v Elevation of inlet: ��� Bottom of tank elevation: — 33 �f � 3 Pump off switch elevation: -!-f--�- � Gallons per cycle: Z3 Alarm Manufacturer: Alarm Switch Type: 1 Number of feet from nearest property line: Front, O'Side, O Rear,0 Ft'2X0 Number of feet from well: Number of feet from building: (Include distances on plot plan). . SOIL ABSORPTION SYSTEM Bed: Trench: �- Width: �� LenEh: Number of Lines: Z Area Built: c� Fill depth to top of pipe: C51-it Number of feet from nearest property line: Front, Side, O Rear,O Pt 's' Number of feet from well: Number of feet from building: (Include distances on plot plan). SLEPAGE PIT Size: Number of s: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a dro box O or distribution box O been used on any of the above soil absorbtion s ems? (Check one). HOLDING K Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from arest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: umber of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: � � � T 3/84:mj Form - STC - 104 b AS BUILT SANITARY SYSTEM REPORT OWNER .�..r 1,Ls� s�f TOWNSHIP '�y� SEC. Z� "-R�W ADDRESS ! ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -<, f atb � v �0 yC INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point usedl, Elevation of vertical reference point: Proposed slope at situ: �Q SEPTIC TANK: Manufacturer Liquid Capacity: -i'``"=" Number of rings used: (0 Tank manhole cover elevation: 0 27 ��� Tank Inlet Elevation:��j —/Tank Outlet Elevation: Number of feet from nearest Road: Front aside 0 Rear, O . feet From nearest property line Front,aSide,O Rear,O feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) , SEE REVERSE SIDE r { DEPARTMENT OF INDUSTRY,' INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 79(19 BUREAU OF PLUMBING MADISON*WI 53707 NW ,NW 4,522, T29N-R17W $CONVENTIONAL ❑ALTERNATIVE Sate Plan I.D.Number: Town of Hammond ❑Holding Tank El In-Ground Pressure El Mound WV 19 NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Walter Longens Route 1, Hammond, WI 54015 y-,�/- 9'7 /.'Jd BENCF}MAytK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Piumbe. MP/MPRSW No.: County: Sanitary Permit Number: Gary L. Steel 3254 St. Croix 92502 SEPTIC TANK/HOLDING TANK: MANUFAC URER: LIQUID CAPACITY: TANK INLET ELEV.: JANKOUTLETELE JW LAB L LOCKING COVER P OVIDED: PROVIDED. /0-" 1 YES ❑NO DYES ONO BEDDING: VENT DIA.: VENT MATL.: HIGH WA R NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM .23a LINE: / J 1 AIR INLET OYES ONO 1E]YEs ONO NEAREST IV,_3o ]' DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIP O MANUFACTURER. WARNING LABEL LOCKING COVER V DD / ,� v r PROVIDED: PRO IDED: YES ❑NO (/�(/�/ D YES ❑NO YES ONO GALLONS PER CYCLE: 11NI1CONTROkS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) YES ❑NO NEAREST 9.36 16' SOIL ABSORPTION SYSTEM.Check the soil moisture at t e depth of plowing LENGTH: DIAMETER MATERIAL AND MARKIN�G- , n or excavation. (if soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN J L' CONVENTIONAL SYSTEM: WIDTH: LENGTH: IN0.0F 173,5.PIPE SPACING: COVER INSIUE DIA. #PITS LIQUID BED/TRENCH �� TRENCHES: MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTR PIPE DISTR.PI E DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV NLETELEV.�[JD: PIPES. FEET FROM LINE2 AIR INLET. Q o. 4 Y� NEAREST--N- ✓b � 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 R EVE RSESI DE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ❑NO OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. SEEDED MULCHED. CENTER EDGES. DYES E1 NO I DYES ONO OYES El NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIF0 L.D DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV.. ELEV.: CIA.: ELEV.. PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY ]'COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES ONO DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES F-1 NO -]YES El NEAREST L . f Sketch�n't on Retain in county file for audit. Reverse Side. DILHR SBD 6710(R.01/82) 1 SIGNATURE: TITLE. Zoning Administrator PAGE: CF PU7"1P CHAMBER CROSS SECTION ANG SPECIFICATIONS VENT CAP 4�Ca. V[WT PIPC WCATHER, PROOF APPROVED LOCKING—T JUWCTIOAI BOX fAAM14OLE COVER LS,' FROM DOOR, • MIINDOW OR FRCSH It MIU. Nit IIUTAKE. GRADE i yMiiJ. IB•rnu. COWDUIT L-- ----------- PROVIDE I �" INLET AIRTIGHT SEAL jAPPROVED Jowl APPROVED JOINT A I I I W/C.X. PIPE W/C.t.PIPE I 1 I I ALARM EXTENDIM& 3' EXTENDIW4 a'; ONTO SOLID SOI OUTO SOLID *OIL A j ou ' E.LEK 9 38 FT PUMP-� --J Orr CONCRETE BLOCK , RISER EXIT PERM11rE0 OIJLy IF TAWK MAIJUPACTURER HAS SLIGM APPROVAL ISEPTIC s P E c l F l'CAT I OA1 s 0059. Weeks _Concrete WAVER OF DOSES: 14 PER o" iAr /MANUFACTURER.- TA JK SIZE:- 800 6ALLONt DOSE VOLUME 154-92 • INCLUOIAI6 6ACKFLOW:���•-+ ---GALLON P WUFACrUItER: tank alart MODEL IJUMeER: CAPACITIES: An -.WC CS OR 4�� LOL1 SWITCH TvpcI mer.cllp, d s-�..IIJCMES -.WALLOW pu�P MAIJUFACTURCR: �""�a C. 7IQIt14LS OR 1156 G/►LLOLI �. WE031 -- D _12.._II�ICHES OR 2CzZ-: GALLOIJ MODEL NUMBER: SWITC/1 T11Pt.. mercury COTE: PUMP AND ALARM ARt TO BE INSTALLED OIJ SEPARATE CIRCUITS MIIJLMUM DIlCMAR6C RATE,9.0 VERTICAL DIFFERENCt BETWEEN PUMP OFF AWD 018TRIBUTIOW PIPE.. 8-70 - FEET ♦ MINIMUM NETWORK SUPPLY PRESSURTE/. . . . . . . . . . . xFA FEET 22.294 gal/in. ♦ 3_FEET OF FORCE MAIN X —r/foo r1FR'CT'OU PA';TOR•._ 2 FEET TOTAL 091 AMIC. HEAD FEET t WS OF TA LEU&TH 81 _ ,WIDTH 49 iLIQUIDI DEPTH .. .-- >yTERNAL. DIM U sloNSO: � '> � LICEIJSE IJUMOER: 32'54 DA'TE: 3 1-.�:7 :1 ■■■■■■■■■■■■■■■■■■■■ a e . %'■■■\■■■■■�■\■■■■■■■■■ Mm 10. ®®■■■si :riS►iii°iii■■■■■■ ®�®■■■■■■■■■■■■■■■ MODEL : : ■■■■■■■ ■■■■■■ Solidi 1 ■®■■■■■■■■■■■■■■■■■■■■■■■■ / �■ ■�■■■■■„■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ , ■■■■■■ W■■■■ ■■■■■■■■■■■■ ' ■■■■■■■M■M■■■■■■■■■■■■■■■ I;,I c 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 owrer'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; Vlll. 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 81/2 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; (Jose 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. ------------------------------------------------------------------------------I------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the {{ result of over 2 years of steady negotiation and public debate. The groundwater bill Ground-- tAter included the creation of surcharges (fees) for a number of regulated practices which Wisco 'trt'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reaSUre is used in your b jilding is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. The rnonies collected through these surcharges are credited to the groundwater fund adminis- ereb by the Department of Natural Resources. These funds are used for monitoring ground- t :;rater, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) -�- SANITARY PERMIT APPLICATION COUNTY �0ILHF In accord with ILHR 83.05,Wis.Adm. Code St. Croix STATE SANITARY PERMIT# s 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. 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE YES ONO PROPERTY OWNER PROPERTY LOCATION Wal ter Longens NW '/a %, S22 T2Q , N, R17 (or)W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK Hammond Wi. 54015 n a VILLAGE: Hanmtond Hy. 412 II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. 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. nx 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. ❑ 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): 2 495 500 99.58 Feet ®Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank x 1000 1 Weeks Concrete Fil El I EF ❑ Lift Pump Tank/Siphon Chamber X I 1 800 1 Weeks Concrete ® ❑ ❑ ❑ 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) XX/MPRSW No.: Business Phone Number: Gary L. Steel 1 3254 ] (715 246-6200 Plumber's Address(Street,City,State,Zip Code): Name of Designer: 988 N. Shore on W' . Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# Gaa L. Steel 2298 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: and i 715 246-6200 IX. COUNTY/DEPARTMENT USE ONLY ® ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination A6 C) •UQ •d0 ��/�—�` U p /U(,Gjc)r j r/Yf� 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 �- - - - - -_- -� - -� i' �� �� � yG�' (� �rC�y�`� ' � �i ��j 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 Walter Long�en Location of Property NW 14 NW 1y, Section 22 , T 27 N _ R17 W Township Hammond Mailing Address $,g,#1 Hammed, Wi, Subdivision Name n/a Lot Number n/a Previous Owner of Property Federal Land Bank Total Size of Parcel n/a Date Parcel was Created 3-11-85 Are all corners and lot lines identifiable? x Yes No Is this property being developed for resale (spec house) ? Yes x No Volume 709 , and Page Number 417 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. • Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - PROPERTV OWNER CERTIFICATION I (we) CeAt16y that att dtatemente on thiA 6otm aice true to the beat o6 my (oun) hnowtedge; that I (we) am (are) the owner(4) o6 the pro peaty du cA bed in thi4 in6o4mati.on 6onm, by vixtue o6 a wauanty deed neeonded in the 066ice 06 the County RegiAten o6 Deede az Document No. 401031 ; and that I (we) pnee ent,ty own the pn opoe ed A to bon the 6 ewag a po— a yd tem (on I (we) have obtained an eaeement, to nun with the above dedeh.i.bed pnopenty, bon the eondtn.ucti.on o6 ba.i.d aydtem, and the dame has been duty neeonded in the 066tee o6 the County RegiAta o6 Deeda, ad Document No. ) . SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 3-12-87 DATE SIGNED DATE SIGNED 3 K r g$ p I� k C: g �T fi 4 Pt : t. ws, and ift mvwuk Nom}� Ukrx t To'Ok- 2 ± eft iL Iv Av K RT . r . a5 y . =a €k-f z _ - h m T' 4 7 i a .. {ewv.. � c.£�:4i'� i�'• -.�fr td's-,Y: r� _ ST C - 105 a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a OWNER/2309R Walter Longen ROUTE/BOX NUMBER R.R.#1 Fire Number .CITY/STATE Hammond, Wi ZIP 54015 PROPERTY LOCATION: NW , NW , Section22 , T2_N , R 17 W, Town of Hammond , St . Croix County, Subdivision n/a Lot numbern/a 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. Ho E I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b 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 DATE 3-12-87 St . Croix County 8 Zonin Office P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report roust 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 anew or replacement system; 5. 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; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; S. Make su,Ke your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. 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 not apply, place N.A. in the appropriate box; 11, 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.. I i ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols � st Stone (over 10") BR — Bedrock cc_,tr Cobble (3- 10") SS — Sandstone gr Gravel (under 3") LS — Limestone *s - Sand HGW — High Groundwater cs Coatse Sand Pearc Percolation Rate mEd > -- Me drurro SeIrld tN kN ell is .- Fine Sand Bldg — Building a is Loamy Sand -- Greater Than °sI — Sandy L=,)arr, < -- Less Than 'I — Loam Br, — Brown `sil — Siit Loam BI Black si — Silt Gy G,1 al c - Clay Loam `r' ._ Ye310IN s -_ Sandy Clay Loam R — Red sic( -- Silty Clay Loam mot — Mottles. sc -- Sandy Clay wr - with r s?c - Silty Clay f1i -- fC,W, line., faint c Clay cc — comnron,coarse tai - Peat mm — Many, nr dium m — Muck cl -- distinct P __ ptornmer t HWL — Nigh water level, Six general soil textrsresrr.fce water _ fo€ liquid vvaste disposal BM — Bench Mark VRP -- Vertical Reference Point TO THE OVVNER: i` SO!! tPSI report is the first step ill securing a sanitary perririt. The county or the Department may reclrrest z ca iMl Of this soil test in the field prior 'o permit issuwicea A complete, set of plans for the private a o V%'e -t <Fnd "II pertrrit application must he suhmitted to the appropriate local authority in order to 'unit. f tee Sa rlitm y pl t snit r11115"l: he Cal3o led and posted p €onto the Start"of arty construction, - I i I L D,LPARTM`IiNT OF REPORT ON SOIL WRINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND . • PERCOLATION TESTS (115) P.O. BOX 7969 H.UMAN,RELATIONS \ / MADISON,WI 53707 • (H63.090) &Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ TY: LOT NO.:BLK. O.: SUBDIV S N NAME: u, 1/a U , Zz /T,�N/R/ (or)W C N OW R'S°".� S MAILING ADDRES 54 - & d r` USE TI ONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION Residence ❑New 5Q Replace �+- D � RATING:S=Site suitable for system U=Site unsuitable for system (J C G� COa NTIO❑NAL: MOUND: IN-GROUND-O URE: SYSTEM-IN-FILLHOaLDING TANK:REC� ED SYSTEM:(optional) If Percolation Tests are NOT required DESIGN RAT/: Q If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: 1 PROFILE DESCRIPTIONS BORING T TAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,C4DEOR,TEXTURE, AND DEPTH NUMBER ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 83 ®�38 7 S Lo B- B- B- �1 _. 1 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER E$ AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P d0 P_ s! 4P l0 L►3 P- 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. SYSTPM ELEVATION I 7 3 ..... t t r 1 IN- �� f , � � -I 0 � ...� _�, _�_ _,eel 1 1 _.' _ ._ . . . (ohs r 1 .. _ _._ - � tip, _ _ E I,the n rsigned, 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 Admin strativt 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: /a . 3 -� ADDRESS- CERTIFICATION NUMBER: PHONE NUMBER(optional):JA CST SIGNATUW. DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — Walter Longens NW4 NW'j 5.22 T29N R17W Hammond, township 00 Gary L. Steel 988 N. Shore Dr. New Richmond, Wi. MPWRS 3254 3-11-87