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HomeMy WebLinkAbout020-1042-80-000 7 0 ` � & o � § 0 \/ 0 k C) )_§ ® ) Q7 ƒ » 0) � 2 ]%) }:bo 222 $ ) � k«\k L ) o � ] §k{/ < 3�- a . � \ 0) i § E z z & z (D § $ ( z 2 . t $ :t § $ U) w c k m \ [ (U cl- § § / / . z m z G 0 t k 0 R 2 4 £ \� � - ©2 f=2 o% 2o k 0 a k I$ / tE - �5 � • $ 6 2 2 2 t m j 2 § ca k k 2 C § r _ � � ° moo I (D ƒ § , § [ � / m ° k k k �IL § c @ 6 - $ @ Z I c - & C) s § . e z z a g a , 2 a q = $ $ a s E E c m C,4 a f S co c, z $ / / \ � 2 � - , _ _ - a CL w J c k a § / / a m A 2 J p�p a� 0. 0 (� ° c ` �0 O " N p °v c G)-a vJ NC lV R ° N r t -mz o- F. N M YN f0 X U d N O V o ° T .2 v v c Z O° Yom L m i tL Z H . U .�- f6 0)'O f6 C Za+ O N C B co 4) O L z E v` Ea co co F->cE � o rn N W d m U C m N C-N N w N c•' �"' fn C ..N.. .'d 16� N C C N o w N d a12'o i Nt.. O Z V p N N V N N C C y -0 no c o °o v o N o E g NF-m N N C: no 0Y L-• I p C N CL N N Vl CL C. L c 0 n -O N f>'0.a O O an. ' Cox.._ cN >v o z m z N L_ LO N N � m, I pit E 0 w O c La CL w = c o a E t E �. O O EL in 0 0 0 0 • � aaa IL 75 U) J U rn rn y O m o c n a .-. m N C N Q } Q �_ 5 N O O w a N CD 0�0 m O U.1 4) O O C a N N N N F- w N v) N to N d• �- v f 1,2 C N N C O O N N Z Z LO '7 Mai O N 'O � "'' 7 E to U • ,�' O 2 0000 O Z N H H tv IL O � v Cq EL m ° d 2 F CL E t c F o r A c°� aa 0 a) v 7 PUMP CHAMBER Manufacturer: 04" 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,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: e6vA Ulµ.i 1,c".t 4 l Trench: Width: Length: w Number of Lines: ` Area Built: �sq?7 Fill depth to top of pipe: 0 2 i Number of feet from nearest property line: Front, O Side, ( Rear,O Pt ..�.r Number of feet from well: l�js / lcc�� Number of feet from building: s (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 /V Q 0 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, Q Ft. h p I Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: 441 � - y License Number: A� lr4 3/84:mj t Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER.-SIT �?t ��+ �/ i� TOWNSHIP �/j_( t/ ,'�j Cr/ SEC. 147 T 0?9 N-R ADDRESS ABC, ZZ ST. CROIX COUNTY, WISCONSIN SUBDIVISION t ,f LOT Ot ! LOT SIZE //2.' e t y' if PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _ _ T'It r t C W It, 4. TT i INDICATE NORTH ARROW rs BENCHMARK: Describe the vertical reference point used-,, . cy Ptz Elevation of vertical reference point: MOZ Proposed slope at site: / w A/,it/. SEPTIC TANK: Manufacturer: Ujv,% I cy, Liquid Capacity: 1 d7C70 as Number of rings used: Tank manhole cover elevation: SD Tank Inlet Elevation: Tank Outlet Elevation: / :�, V0 Number of feet from nearest Road: Front 10 Side, Rear, O 7s feet From nearest property line Front,O Side,®Rear,O 5,Af-eet Number of feet from: well building: ��/�' o�� / �pn� Car nG,✓ (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE J I Parcel #: 020-1042-80-000 12/07/2005 01:42 PM PAGE 1 OF 1 Alt. Parcel#: 19.29.19.173B 020-TOWN OF HUDSON 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-MILLER,SAM E SAM E MILLER PO BOX 151 HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): "=Primary Type Dist# Description '377 BAER DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 6.000 Plat: N/A-NOT AVAILABLE SEC 19 T29N R1 9W SE NE LYG BETWEEN RR Block/Condo Bldg: R/W&HWY A Tract(s): (Sec-Twn-Rng 401/4 1601/4) 19-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 434/576 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 91710 208,500 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.000 93,000 119,600 212,600 NO 05 Totals for 2005: General Property 6.000 93,000 119,600 212,600 Woodland 0.000 0 0 Totals for 2004: General Property 6.000 64,000 100,100 164,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 .Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LEjBOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 000NVENTIONAL ED ALTERNATIVE state Plan l.D.Number: (lf assigned) El Holding Tank El In-Ground Pressure F-1 Mound NAME OF PERMIT HOLDER: ,moo T ESS OF PERMIT HOLDER: INSPECTION DATE:Sam Miller �-�^^' . 1 , Box 282, Hudson, WI 54016 C — 7 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: SE NE, Section 19, T29N—R19W, Town of Hudson, Lot #1 Name of Plumber. MP/MPRSW No.: County: Sanitary Permit Number: Doug Strohbeen 5432 St. Croix 88462 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LAB L LOCKING COVER P V D: PROVIDED'. O / YES ❑NO ❑YES NO BEDDING: IVENTDIA.. VENT MAT/L.': HIGH WATER NUMBER O : PROPERT WELL: BUILDING: VENT TO FRESH L� �°� ALARM: FEET FRO / LINE �� f � Q INLET. OYES ` OYES ONO INEAREST!!;—�ROAD 7s (/ J DOSING CHAMBER: MANUFACTURER-. BEDDING: LIQUID CAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO DYES ONO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VER TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE PUMP ON AND OFF) OYES ONO 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 the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: ILINITII,(8 jN1,OF DISTR.PIPE SPACING. COVER JINSIDE DIA. #PITS LIQUID BED/TRENCH Q TRENCHES / MATERIAL' PIT DEPTH DIMENSIONS V ! GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: O. TR. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET ELEV.EpaND: �t PIPES FEET FROM LINE:/� AIR INLET. I " Lila Q a ,V 5 �+ _ 6 NEAREST--► OJ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ❑NO OIL COVER ITE XTURE PERMANENT MARKERS OBSERVATION WELLS DYES ❑NO OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED :7TOPSOIL. SODDED SEEDED MULCHED CENTER: EDGES. DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV.: DIA.. ELEV.. PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: re 7 e� ❑YES ❑NO ❑YES ❑NO NEAREST O 35 Sketch System on in county file for audit. Reverse Side. URE TI''TLNNE.,�� I DI LHR SBD 6710(R.01/82) 1 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 systern, 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; 11 Type of `r_toilding or use served: I( public s 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; M. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repai r; 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 a//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 8Y2 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 Ground gt�i— included the creation of surcharges (fees) for a number of regulated practices which Wiscor4in's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buriedf &s!!C@ is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. c The monies collected through these surcharges are credited to the groundwater fund adminis- tereei b the Department of Natural Resources. These funs are used for monitoring ground- groundwater p 9 9 t u..:ater, groundwater contamination investigations and est ablishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) �' DILHR SANITARY PERMIT APPLICATION COU Y In acgord with ILHR 83.05,Wis.Adm.Code • �� STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLA91.6.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 E'/4 E'/4, S TZ , N, R E(o PR PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK WMBER 'SUBDIVISION NAME Z l0 SQ CITY,ST TE ZIP CODE PHONE NUMBER 0 CITY NEAREST ROAD,LAKE OR LANDMARK T O/ a ❑ VILLAGE: II O II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family R OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. X New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. VW 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. K 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: (Minutes per inch): REQUIRED(Square Feet): PROP OSED(Square Feet): C l l s_S _T 6, �� •3 Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in ga ons 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 00 0 ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ Li 0 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: PI tuber' Address(Street,City,State,Zip Code): Name of Designer: IGI,9 Al. /� r � � nr o C/ �� s VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# � r ls4ob h e r -? CST's ADDRESS(Street,City,State,Zip Code) F Phone Number: / &/I X401(0 0/-57) 384-59 8/ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater I pate Issuing Agent Signature(No Stamps) VApproved ❑ Owner Given Initial Surcharge Fee �'� Adverse Determination 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 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 SltJ , Section / , T---?g N-R _Z ,9 ZW,) Township �Z Mailing Address L Y Z Address of Site �,� / (8 p V s� c•1.4 Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel — G Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number r _s� as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: 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 Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPFRTy OWNER CERTIFICATION 1 (We) centiby that aU statements on this bonm ah.e true to the best ob my (oun) know.Qtedg e; that I (we) am (cue) the owner(s) o6 the pro pen ty des cA i.bed in thi.6 .inbonmat on bon.m, by viAtue ab a wa Aanty deed necanded in the Obbice ob the County Regi,sten o Deed6as Document No. s l ; and that I (We) pnesentt own the proposed bite bon the sewage diApodaZ.s ys� (on I (we) have obtained an easement to nun with the above dedcA bed p%opeAty, b on the constnuction o6 said system, and the same had been duty neconded in the Obb.ice ob the County Reg.cdten ob Deeds, ad Document No. SIGNATURE OV OWNER SIGNATURE OF CO OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED i ' DOCUMENT NO. STATE BAR OF WISCONSIN-FORM 2 WARRANTY DEED Vol r; 7J THIS SPACE RESERVED FOR RECORDING DATA ct::C.L.:i tiI 5 QF F11,E Arnnl d R_ RertPl sPn and Vi rninia A. Rert•al sen, ST' 0^0IX CO., WIS. ---__ _husban tenants tie='�. ft�r !?� c��r;i INS 7th da3, of Feb, A.D. 19 80 conveys and warrants to Sate F_ Miller ( at 12: 0f� _ Rep&ter of Dude RETURN TO the following described real estate in St. Croix County, State of Wisconsin: Tax Key No. That part of the East one-half of the Northeast one-fourth (E 1/2 NE 1/4) of Section 19, Township 29 North, Range 19 West, lying Northerly of the railroad right-of-way and South of I County Trunk Highway "A". EXENM- This . is not homestead property. (is) (is not) Exception to warranties: Dated this 1st day of February , 1980 SEAL � '2`"— SEAL) Arnold R. Bertelsen (SEAL) 1 :: 1 0,01 tA �I� (SEAL) Virginia A. Bertelsen AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this 5th day of STATE OF WISCONSIN ra _Febru I..lg Ss. County. � 7 Yersonaily came before me, this day of *—Wj_jliata-J nrjAseyich the above named TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) This instrument was drafted by William J. Radosevieh to me known to be the person_ who executed the fore- Attorney at Law going instrument and acknowledged the same. Hudson, Wisconsin 54016 '(Signatures may be authenticated or acknowledged. Both are not necessary.) Notary Public County, Wis. My Commission is permanent. (If not, state expiration date: , 19 .) WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2-1977 Wr.�r�rp larva All - � IA �r � N tv CS kA CN Wks r � T A C a LA N A F a J a i �" '4� H z N a . r STC - 105 r • a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z t7 a OWNER/BUYER .57 ��✓ o' ROUTE/BOX NUMBER 6�/ �o� z S` 2 Fire Number.--- .CITY/STATE �/��oh !�C/Z_ ZIP PROPERTY LOCATION: 1%, P/'- 14, Section 4T _, Tc:22N, R If W Town of , St . Croix County , Subdivision 1/0'4 , 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 pdt 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. yo E I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- tin 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. C3 a SIG 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 . s INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report must include: 1 e Complete legal description; 2. The, use section must clearly indicate svnetlier this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. is this a new or replacement system; S. 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; E. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; `r. MAKE A LEGIBLE diagram accurately locating your test locations, Drawing to scale is preferred, A separme sheet may be used if desired; B. Male state your benchmark and verb€aal elevation reference point are clearly shown,and are permanent; 0. Complete all appropriate boxes as to dates,narnes,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the, iriformation (such as flood plain,elevation} does riot apply, place N.A.in the appropriate box; 11, Sinn the form and place your current address and your certification number; 12, Make legible copies aril distribute as re<luired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 GAYS OF COMPLETION, , ABBREVIATIONS FO.R CERTIFIED SOIL TESTERS Soil Sepo,rates and Textures Other Symbols st - Stoma (over 10") BR Bedrock col - Gobble f3- 10") SS - Sandstone ar Gravel '(under 3") LS - Limestone s - Sand 14GW - High Gioundvvater ("S s C,oarsc: S;arib Perc Poi-colation Rate .. .� rued s Medium Sand W - Wt d is Finta Sand Bldc; __ Building Is Loa,iy Saud �3 - Greater Than `sl - Sandy Loam < - Less Than 'I Loam Bn - Brovvn *sil - Silt Loam Bi -- Black si Silt Gy r ;a cl - ';lay Loam Y - yellow scf - Sandy Clay Loam R - Re(J slcl - Silty Clay Loarn mot - Mottles sc -- Sandy Clay w/ ._._ with s, - Silty Clay fff - fevv,mine,faint Clay cc _ coinnacsn, coarse I. - peat rTir - Many, medium n - Muck d distinct p _.- prominent HWL - Fligh water level, Six general soil textures surfaces water ' for liquid waste disposal 8M Bench Mar;< VRP Vertical Reference Paint s TO THE OWNER: t, r so ii tr.st £a r rt is the first str�:) ,rt,,aces€iricl a sar itar-y perrnit.The county or the Department may request oT this soil test in the furled prior to nernnit issuance. A compiete set ol i0ai7s for the privat(-: itn > a and a rue"i-Iii applicati rg i1c tot) t<) the apj lC7tal u'L!LhJri y in order 'too The san iat~ Cle r1-'r',? 3tiP,z( t,f of tained and ?.).._f'd pi iol to the strait of any c;onstrtrction, J DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION eM?Ai;.RE PERCOLATION TESTS (115) P.O. BOX 7969 h�JMAN`RELATIONS \ / MADISON,WI 53707 (H63.09(1)&Chapter 145.045) LOCATION: SECTION: 0WNj HIPA416141"PALLT-Y: LOT NO.:BLK.NO.: SUBDIVISION NA E: /Tt?N/R/?0(9 aw d f-SA4 So, c�y A' rf es iIe..� COUNTY: OWNER'S of W LS UAMC.— MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL D SCRIPTION: I 1PROFIL E DE CRIPTIONS: ER OLATION TESTS: I'mFlesidence 'e ^ XNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system PC— 104,-. CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) ®S ❑U (�S ❑U ; L�JS ❑U DS ©U ❑S DU I Cola a If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: IV14 PR FILE DESCRIPTIONS ee BORING TOTALS ELEVATION DEPTH TO GROUNDWATER-"+eMrt1 CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- .2- 17's, y's:�' /��ou� J .S"' �r a !3 Sl .7. Br If 3.3 B,r h .s 7 elf B- PERCOLATION TESTS TEST DEPTHJ' WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER •1``NGWE£ AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD PERIOD 3 PERINCH P- ! 7 i/ f O I P- Z ' a S (, P-� I'p- P_ _ y' PLOT PLAN: Show locations of percolation tests, soil borings and the di ions �0�i��� ,�o I ar�as.Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on t plot plap' oLd. ur ale elevation at all borings and the direction and percent of land slope. �!0 >•+ i �R��C �*� wa Y. SYSTEM ELEVATION /. ° .` 4a —7,1 1 1 r Ct t �4S Al% 1. loll _ _- B_ 3 r ��G r _._ 3 IN i� If ►�46 c : z 1 __. i r 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 7111 dW- CS ATURE: � DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — cy � I I i I i LA a � \ w c - I o -�L S I • c r