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Parcel #: 020-1056-00-400 12I20/2004 03:57 PM
PAGE 1 OF 1
Alt. Parcel#: 21.29.19.208F 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): *=Current Owner
*LEMON,GREGORY S& DENISE R
GREGORY S&DENISE R LEMON
812 HARBOR VIEW RD
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *812 HARBOR VIEW RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.669 Plat: N/A-NOT AVAILABLE
SEC 21 T29N R19W SW SW 2.669 AC LOT 6 Block/Condo Bldg:
CSM 6/1747
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
21-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 791/467
07/23/1997 784/568
07/23/1997 770/632
2004 SUMMARY Bill#: Fair Market Value: Assessed with:
48045 277,300
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.669 33,400 181,100 214,500 NO
Totals for 2004:
General Property 2.669 33,400 181,100 214,5000
Woodland 0.000 0
Totals for 2003:
General Property 2.669 33,400 181,100 214,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 115
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
001-WATER SPECIAL ASSESSMENT 0.00
Special Assessments Special Cha 0 00 Delinquent Cha 0 00
Total 27.00
PUMP CHAMBER
Manufacturer: /// Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. _
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: doe dcu-f.o.,a/ Trench: ---
Width: l Sr � Length:-3 G Number of Lines: 3 Area Built: &4*1(0'39��-
Fill depth to top of pipe: G/ Z
Number of feet from nearest property line: Front, O Side, Rear,oFt
�
Number of feet from well: D
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT 4114
. 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: /1/ n 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:
/ J
License Number: X4 y4 �^ � 3 2
3/84:mj
Form - STC - 104
w
AS BUILT SANITARY SYSTEM REPORT
OWNER 4;o Ila e TOWNSHIP SEC. 2- / T -A-IN-R /9 W
ADDRESS 12 Lo /g off{ Z Z ST. CROIX COUNTY, WISCONSIN
A/44/50�/ K/ L - 7 a� G
SUBDIVISION Jac°b s I4Hj ~y LOT 41t- LOT SIZE 2' c c✓s
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
IV
V
�4XS6
0
y� 75
d �
INDW4TE ORTH ARROW
BENCHMARK: Describe the vertical reference point used
6
Elevation of vertical reference point: 100-10 Proposed slope at site: -
SEPTIC TANK: Manufacturer: U !�' S c_rf Liquid Capacity: /600 lad
Number of rings used: Tank manhole cover elevation: 96"G
Tank Inlet Elevation: S.to Tank Outlet Elevation: 9y.�
i
Number of feet from nearest Road: Front,O Side,V Rear, O CJs feet
From nearest property line Front 10 Side,P Rear,O O� feet
� i
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.dOX 7,169 ' BUREAU OF PLUMBING
MADISOI$ WI fl37�
SW,SW, Sec. i, T29N—R19W CONVENTIONAL El ALTERNATIVE State Plan 1.D.Number:
(If assigned)
Town o-f Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound
Lot 6, Jacobs Landing
NAME Of PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Sam Miller Route 1, Box 282, Hudson, WI 54016 la_ ;3 d
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: - MP/MPRSW N. County: Sanitary Permit Number:
ouglas Strohbeen I5432 St. Croix 92468
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPA. V: TANK INLE ELEV.. TANK OUTLET ELEV.: WARNING LAB L LOCKING COVER
PROVIDED: PROVIDED.
Y,(-) ❑YES NO ❑YES ❑NO
BEDDING: VENT A.: VENT M( 1 HIGH WAT R 1UMBER OF ROAD: LINE ERTV WELL: BUILDING: VENT TO FRESH
ALARM: / AIR INLET:
FEET FROM 4� .S CL'�
OYES NO DYES ONO NEAREST
DOSING CHA BER:
MANUFACTURER'. BEDDING: LIQUID CAPACITY. PUMP MODEL'.! PUMP/SIPHON MANUFACTURER. PROVIDE PROVIDED:
PROVIDED OVER
❑YES ONO OYES ONO I QYES ONO
GALLONS PER CYCLE: PUMP AND CONTPOLLS OPERATIONAL: NUMBER OF PRIOE AIR INLET.
ERTV WELL BUILDING:JVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) DYES 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
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LEN NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA. PITS LIQUID
BED/TRENCH TRENCHES: M RIAL' PIT DEPTH.
DIMENSIONS �� --- � � �
GRAVEL DEPTH FILL DEPTH UI TR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.01 TR. NUMBER OF PROPERTY WELL. B DING: V NT TESH
BELOW PIPE ABOVE COVER: "V11 INgLET EL �f PIPES FEET FROM LINE' c / Z A L
6 ✓�/ L' !f ✓ 7/77s Z NEAREST-
/ .L!'
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.
❑YES NO
OIL COVER TEXTURE PERMANENT MARKERS OBSERVATION NATION WELLS
El YES ❑NO DYES ONO
DEPTH OVER TRENCH IBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL'. SODDED SEEDED MULCHED
CENTER'. EDGES'.
El YES ❑NO ❑YES ❑NO ❑YES ❑NO
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 VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY 1COVER.MATERIAL
PLANS
DYES NO DYES 0 N
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
DYES 1:1 NO DYES 1:1 NO NEAREST
7 01 b9i
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATUR TITLE.
.�- Zoning Admint.strator
DILHR SBD 6710(R.01/82)
Thomas C. Nelson
I
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
r
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.
I
To be complete and accurate this sanitary permit applica'Jon must include:
I. Property owner's narne and mailing address. Provide the legal description where the system is to be
installed;
Ii. Type of building or use served: li 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;
111. 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 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 Atef
included the creation of surcharges (fees) for a number of regulated practices which Wisco rw ...
e
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried teaSUt6
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.
.o
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(8.03/86)
I
4
1
DILHR SANITARY PERMIT APPLICATION Col TY CIDI
In accord with ILHR 83.05,Wis.Adm.Code
°°• �..�. STATE SANITARY PERMIT#
t V
-Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x.1 1 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
i&C S&J%S q//4,S col / T� , N, R *(or
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
tQ 4104 I& irk
CITY, TATE ZIP CODE PHONE NUMBER Ej CITY NEAREST ROAD,LAKE OR LAN ARK
VILLAGE:
- 0/5 TOWN OR
11. 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. VN 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 Tan k
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. Z Seepage Bed b. ❑Seepage Trench c. ❑See age 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): �
3 4,P a,/ 7 T �o a,/ s �T `j 61 3 Feet ®Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total #of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank ��i �r ❑
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:
Plumber's Address(Street,City,State,Zip Code): / Name of Designer:
L r, 1 f (/ f 23
Vlll. SOIL TEST INFORMATION
Certified Soil Tester CST)Name CST#S
CQ l t owa, s �� S
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
Al (71S 27W-473-5-
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial ^� S h rge Fee Q ' — n Adverse Determination / Urate
—/��U` �"1�'� •"`' 1 v �7 e
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03186) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
Form - S T C 100
Owner of Property
Location of Property Sw �LtJ �, Section ,T N R�
Township��cA o✓i
Mailing Address 90e
Subdivision Name �Q Co s L n d( H
Lot Number
Previous Owner of Property� ���
c
Total Size of Parcel
Date Parcel Was Created.- >���/77
Are all corners identifiable? _ _Yes No
7?O
Include with this application one of the following :
. Certified Survey Map
e e �-
. Land Contract , or
. Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION
(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. VZ 30 Z 3 ;and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an 0asement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No. VZ3o .3 3 ),
SIGNA�8F_OF OW
NE SIGNATURE OF CO.OWNER (IF APPLICABLE)
DATE SIGNED. DATE SIGNED
H
• z
• cn
y
a
' r
STC - 105 y
y
SEPTIC TANK MAINTENANCE AGREEMENT p
St . Croix County z
0
a
M
OWNER/BUYER iY1 /�!/ �
ROUTS/BOX NUMBER �� � ' Fire Number /� .
.CITY/STATE [�aOSOkl �- ZIP `����(°
PROPERTY LOCATION: '5(0 1%, ���. Section / , T ?Zq_N , R
Town of �u�Sc"� , St . Croix County ,
r ;ti
Subdivisions , Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
gists 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
H
three year expiration. o
E
z
I/WE, the undersigned, have read the above requirements and agree C„
to maintain the private sewage disposal system in accordance with rx,
the standards set forth, herein, as set by the Wisconsin Depart- 'd
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Offi;re within 30 days
of the three year expiration date .
SIGNED
E_3 -__L !j
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 .
DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
' WARRANTY DEED
REGISTERS OFFICE
�'�"�;3rU.3� BOOK 770 PA":E J2 ST. CROIX CO., WI&
` Rec'd. for Record IMs . 5th
This Deed, made between -•-.
Virgnia._M.___Hanso _-a_.._________ day of
single woman MU��AD 1987
------....-••• -----•-•-- .......... -------•---------------------------------------------
of 11:45 A , hL
.................. -----•--.....------------•------•----------........---------------.....-- ................
Grantor, James O'Connell
and......:..::::..:..:Sam--
Miller,_:_d/b/a�..Sam-.Miller..Construction-:-. r• � �
.............................................. -•----•--•----------------------------••---- ..................... !'' deputy
.................................................................................................., Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
.........................Qlle---aollar__=.d._other__yaluable__consideration-
' RETURN TO
conveys to Grantee the following described real estate in ......,S.t....-CrD.Ix.........
County, State of Wisconsin:
Tax Parcel No: ...................................
Part of the SWJ of the SW4 of Section 21-29-19, described as follows:
Lots 5, 6, 7, and 8, Certified Survey Map filed November 19, 1986,
in Volume 11611, Certified Survey Maps, page 1747, as Document #419479.
Subject to recorded easements, reservations, and rights of way.
Wi
This ---------I$..IIOt......: homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And.......... M. Hanson
-------------- -------- -----..... --- •---... ...----•- --•--------•--•••• -••---.
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
no exceptions
and will warrant and defend the same.
Dated this ...----- 4th ------•---••-- day of •..................March----------• ---••--- 19..a7...
----------- -••--- -•------•-•--•-•-- ---•----------••------- -------(SEAL) ----
. .... SEAL)lanson
........................................................ ------•- K
---------------------------------------------------(SEAL) ---------------------------------------- ------•-----.....-- •--....(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
O STATE OF WISCONSIN
Signatures ......V��:g�B�i�._�.�._���Q21..................
SS.
------------------------•-•----------•-------.......••-------------••-••-------• St. Croix
March
authenticated this t�?.day of......March..__. 19 ---- .................•....County.
$� Personally came before me t is .AtA.......day of
•----- --------••--............ ........, 19...-7. the above named
•-••--•...............•---.....---------•--••••-------•......--•••-----•-••----. Vir inia M Hanson
Eric J.._ Lundell
TITLE: MEMBER STATE BAR OF WISCONSIN
-•--•-••---------------•------------------------•••--•--=- -n-••-----------•--•-
(If not, .................................................... �;jt'...."...: .......
authorized by § 706.06, Wis. Stats.) to me known to be the person ----->•. who executed the
foregoing instrument and ackno_ .],edge tro•samp.. i
f THIS INSTRUMENT WAS DRAFTED BY
I Eric J. Lundell . .--- = _---- ......
............................................ �f/'� J
New Richmond WI 54017
.................................................1........-........._ _. /
Notary Public ........ t_.__Croix': ; . .....Count;. Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(lf 'npy,'1gt4- a expiration
are not necessary.) MM
date: -.. hi_ -o
*Names of persons signing in any capacity should be typed or printed below their signatures.
STATE nna of —1982 WISCONSIN Stock No. 13001
H.C.Miller Company M FL)N11i No. 1—1982
DEPARTENT OF REPORT ON SOIL BORINGS AND SAFETY.&BUILDINGS
M
DIVISION
INDUSTRY, P.O.BOX 7969
LABOR,AND- - PERCOLATION TESTS (115) MADISON,WI 53707
HUMAN RELATIONS, (1-163.090)&Chapter 145.045)
LOCATION:'`� ' S TI N: pD d y TO1(.NSHIP/MUNI P1kLITY: OT NO.:BLK NO.: SUBDIVI l N NAM
/4� / /It [(or)n /'�J�
COUNTY: 'S B YE 'S N JMA� i ^ ,
i r(`/ W'A�
DATES OBSERVATIONS MADE
USE IPT 0 I
®Residence New ❑Replace L
NO.6 DRMS.: 0
RATING:S'Site suitable for system U-Site unsuitable for system - ..
0 N V E N ! NAL: MOUND: IN-GROUND S N-FILL OLDINNG TANK:RE OMMENDED SYSTEM:(optional)
®S ❑U ICJ S C7U ®S ❑U ❑S 0U [IS Izu -
If Percolation Tests are NOT required DESIGN RATE: [Floodplain,f any portion of the tested area is in the
under s.H63.09(5)Ib),indicate: indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH R UNDWATER-INCHES CHARACT R 0 S IL WI H HICK ES ,C E U E,AND DEPTH
NUMBER DEPTH 1010. ELEVATION gg RVED TO BEDROCK IF OBSERVED EE ABBRV.ON BACK.)
B- > d S,4-7 Ar r
B- 7 7
B- > -
g. - -
B- _ -
B - - -
rN .
PERCOLATION TESTS
TEST DEPTH , WATER IN HOLE TEST TIME DR IN WA R L V IN H ER INCH
NUMBER INO+ ES AFTERSWELLING INTERVAL-MIN.
P_
P- f -r_ _i__ I'll, -_-_
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 boringfl�nd the direction and peroent
of land slope.
SYSTEM ELEVATION 9a.-3 _ __......
TA
X
,s
1_s 44f
__-- H
r -
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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.
NAM 1pri t : TESTS WERE COMPLETED ON:
ADDR S: CERTIFICATIO UMBER: NONE NUM ER(o
N ptional):
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DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester, r C>j / �r �{J M) �
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