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HomeMy WebLinkAbout020-1146-10-000 a-°i °o. I p peg ti 0. o � I o II' I 0 N I N I I I o I I I N aD I N c z° °c LL c o I o w v I I Z H rn w E r C � o a °' w N am N Z o O z :t c (n Fz- c I C0 _�V N c cv CID I CL N i (D o a L y I O o 0 ¢ z m z Z Y GC1 N E O d � , 0 > N C CC) 0 G G CL 0cp N C m 1 p N N H 7I O w N N l p d LL Z O O •► LO aaa R _ N I a 3 I C N c r tnJV Nrnrn z = o o O 5 � m c a ov y m rn m am) m Q > Cl) m I 2 w w O p N C O O p 0 V C d > N N C O d p p N N R N N o U coo v1 Q) z :: I N -0 7 I� r j O C_ N • N to O it O N 2 �� LL � O Z N Z F- 2 co v � � n € a I IL I • J 6EPARTWENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS ON I LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISBUREAU OF PLUMBING P.O.BOX 7969 MA 60',V WI 537O7 NE�,SE4,S26,T29N—R19W CONVENTIONAL El ALTERNATIVE State Plan l.D.Number (If assigned) Town of Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 5 High Meadows NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Gary Firkus 1662 E. CTY Road C, Maplewood, MN 55109 //_ `7-oo 7 .3 :6c) BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: 7EF,PT.ELEV. Name of Plumber: IMP/MPRSW No County Samtary Permit Number: David B. Fogerty 3289 St. Croix 102780 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV, TANK OUTLET ELEV.. PROVIDEDLABEL PROVIDED OVER DYES ❑NO DYES ONO BEDDING. VENT DIA.. VENT MATL.. HIGH WATER NUMBER ROAD: PROPERTY WELL. BUILDING JVENTTOFRESH ALARM. LINE: AIR INLET FEET FR DYES ❑NO DYES ❑NO N DOSIN G CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUF AC TIIR ER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING AIR IVENTTOFRESH INLET LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYES 0 N 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: LENGTH NO OF DISTR.PIPE SPACING COVER INSIUE DIA -PITS DEPTH BED/TRENCH TRENCHES MATERIAL' PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH IDISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL BUILDING VENT TOFRESH BELOW PIPES ABOVE COVER. ELEV INLET ELEV.END. PIPES FEET FROM LINE. AIR INLET NEAREST=r, MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ❑NO SOIL COVER ITEXTURE PERMANENT MARKERS OHSEH NATION WE LLS ❑YES ❑NO ❑YES ONO DEPTH OVER TRENCH/BED JOEITH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED F"'U':1YES MULCHED CENTER EDGES. , DYES ONO ❑NO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO,OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF 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 PLANS CAL LIFT CORRESPONDS TO APPROVED DYES ONO 1 ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF LRNE ER RTV WELL: BUILDING. OYES ❑NO ❑YES ❑ FEET FROM NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. TITLE SIGNATURE. Zoning Administrator DILHR SBD 6710(R.01/82) 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,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: V1 Trench Width: �` Lenggth: 7!t . of Lines: Area Built: Fill depth to top of pipe: ;2y k Number of feet from nearest property line: Front, O Side, O Rear,0 It Number of feet from well: _ p� ,5rrriG.�D Number of feet from building: (Include distances on p lot plan). yta�{r yo.yi Er.cO• lozo ' SEEPAGE PIT fi's�c� f97' 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, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alara Manufacturer: Inspector: 1 ti silt Dated: �t11%�� Plumber on ,job: License Number: 3/84:m Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �s�, f�h�CrvJ/ TOWNSHIP , SEC. 2,1' _ T fN-R Zy W ADDRESS //,Z � C/2. Rd' G ST. CROIX COUNTY, WISCONSIN .`u�Hti ss'i0 9 SUBDIVISION ����5 LOT S- LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i ;zr i,goo �.% A i 0 Y. INDICKZ NORTH ARROW BENCHMARK: Describe the vertical reference point used i Elevation of vertical reference point: /4�t0 Proposed slope at si.e: SEPTIC TANK: Manufacturer: Week Liquid Capacity: Number of rings used: Tank manhole cover elevation: _ 2°f, q Tank Inlet Elevation: Z Tank Outlet Elevation: 9?.oG Number of feet from nearest Road: Front 10 Side,O Rear, O ?im feet From nearest property line Front,O Side Rear,O /y0� feet Number of feet from: well yep- 5 /;`(building: (Include this information of the above plot plan)( 2 reference dimensions to3eptic tank) SEE REVERSE SIDE r 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: ✓ Trench• Width: 15- Length: 71/ Number of Lines: Area Built: Fill depth to top of pipe: �y" Number of feet from nearest property line: Front, O Side, O Rear,0 Pt . �B Number of feet from well: � isry Number of feet from building: (Include distances on plot plan). EncO• fD.2o ' 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, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: I _Dated: it itr�L Plumber on fob: License Number: 2�'y 3/84:m 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 maybe 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: 1. Property owners 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; 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 dimer�sjAns, location of holding tank(s), septic tank(s) or other ti6aitment tanks; building sewers; fells; water r� hs/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 crf'steady negotiation and publi'c•-debate. The groundwater bill '. Gr6und�atet included the creation of surcharges (tees) for a number of regulated practices which Wiscorl�in`s can effect groundwater. The surcharge. took effect on July 1, 1984. All of the water that .luried LeaSt1Ce: is uses ir? your building is returned t{, the groundwater- through your soil absorption o system or the disposal site used by your holding tank pumper. G T 6 , or s _>lic Aed through there surcharges are cred+=ed To the groundwater fund adrr.:ris- iere: by °Ae Department of Natural Resources. These fund's are used for monitoring ocound- � +tE;" g ^ ;s:"fwa''er conta-ninatiori in,est;gat ':Dns and establishment of standa-dS :;r{; 1nC atF;; L .°'s worth protecting. oD-6398 f9.03/86', DILHF� SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code .;...,.v.... �.,n. STATE SANITARY PERMIT# /Vayto -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 81/5*x'11 inches in size. -See reverse side for instructions for completing this application. PETITION W. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES V NO PROPERTY OWNER PROPERTY LOCATION 4e S N % C 1%, S 2 1. Tjtf 9 , N, R E (ord) PROPERTY NER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME Z e4 z G L A5, CITY,STATE P CODE PHONE NUMBER CITY NEAR ST ROAD,i-AI( OR4_-PePIBMfcR D 7 ❑ VILLAGE II. fYPE OF BlIJILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family y OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. [5NeW 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. Roonventional 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. []rSee a e 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): ry Feet u Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank / — ❑ 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: C 3. 7 Plumber's Address(Street,City,StWe,Zip de): Name of Design W !�- VIII. SOWT5914INFORMAT40N Certified Soil Tester(CST)Name CST# I\ .X .3 CS ADDRESS(Street,City,State,Zip CoM Phone Number: C.11 L F-k UtJF c.d , a X3 _ IX. CO NTYIDIE0ARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater I Date Issuin Agent Signature(No Stamps) V{fp` Surcharge Fee ❑ Approved Owner Given Initial � Adverse Determination V •�.rCS ,® , X. COMMENTS/REASONS FOR DISAPPROVAL: Pl,qr\ 0,RNL),g,,j btj 'AOMOLS 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 ���' , Section L , T 29FN-R� W Township Mailing Address -C s Address of Site Subdivision Name Lot Number Previous Owner of Property ?1'� Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Y" Yes No Is this property being developed for resale (spec house) ? Yes i/" No Volume and Page Number V//.Y 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPtRTY OWNER CERTIFICATION I (We) cekti.6y that att ztatement6 on this 6onm cute tl(.ue to the but ob my (owc) k.nowtedge; that I (we) am (ane) the owneA(.6) o6 the pn.openty descAibed in this in6o,tmat on 6ohm, by viAtue ob a waiAanty deed necohded in the 064ice o6 the County Reg.c steA o f Deeds as Document No. 35_7 7/ L ; and that I (we) pees ent.2y own the pnopoded site bon the sewage dispod (on I (we) have obtained an easement, to nun with the above dacAibed ptopehty, bon the constnucti"on o6 said dybtem, and the .same hays been duty teco&ded in the Ogb.iee o6 the County Reg-usten o6 Deeds ass Document No. 3 S' 77 SIGNAT OF OWN SIGNATURE ,OF �O-OWNER (IF APPLICABLE) f 4A� DATE SIGNED � DATE SIGNED M� DOCUMENT NO.• WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA II STATE BAR OF, WISCONSIN FORM 2-1982! 430795. �� � ' eoaK 792 ?!�E 59� _)� --- I REGISTERS OFFICE GAn..A....Waxon..Tr-ust-,...G1.en..A.-..W-axon,.-.Tr-us-t.ee.,...an ST. CROIX CO., W/IS. .......t.he..Vyc.ella..M..-.W axon..Truat.,...Vycella:-M.-..Waxon,.. Recd. for Record this 5th Trustee.,...t.a..e�ch..Trlist..a-.one-half-._i.nt,exezt..as.. of Oct. ...t.enants...in..common...... .... ��• 195 ..................................._................ 8:30. A — . I conveys and warrants to ......Gary...C....F.irkus..and..Marlene--.M..-... i .........Firl-us.,--•hu.sba-nd-•a-nd--wif-e..ate---sur=uivors-hip------------- I /� --------marl-tal---pr.o Pe-rtY--•------•.......................................................... a�l�r N Dw/� ..-----•..............................•--•--•-•-•----...............................---••--••--.....----••--•-•-. ....-----•-----•-••-•--- ------------•---------.........---•--------------.........--------•-•----••--------• _ ..............`.................................................................................................. RETURN TO ... ..... ............................................................................................. . ..................... ..................................... ....,................._................ .. .... the following described real estate in s.. • ..ro1X tl ........:.......................................County, State of Wisconsin: Tax Parcel No: ......................._._.... Lot 5, High Meadows in the Town of Hudson, St . Croix County, Wisconsin. DjuiS � F'E � . This 1.. nOt homestead property. (is) (is not) - Exception to warranties: easements, restrictions and rights-of-way of - record, if any. I3ated 111s ............se.cond--------••....•--••... da • of Oo ober........... ..... 19..$7... ................................. .... .........----(SEAL) ...:.-U . �v......`. �...............(SEAL) , G en A. Waxon Vycella M. ;Waxon ....----•---•---...................•-••--•--•..................... .................•-•----•-------•-•----.....----..---- (yEAL) '•.............................................................(SEAL) • i AUTHENTICATION ACKNOWLEDGMENT Signatures) .._.-G"dell..A,-..Waxon.,..VycE11a-.--. STATE OF WISCONSIN ` M. Waxon ss. -------•----- ----------------------------------------------------------------- f ._---•--•.............................County. authentic ed this -_.-..day of.QC.t4�?.�r'._._.-..., 1987.. Personally came before me this ................day of � izfl lyGJ �Cp� Grp-- ..........................................9 19_...._.. the above named .................................l................_...._....._----•---......_.. _.........._.................................................................... . Kristina Ogland Lundeen ...............-•............................................................. ................................................................................ ; TITLE: MEMBER STATE BAR OF WISCONSIN (If not. ..............•--•--•----.............----•------------•--- authorized by § 706.06, Wis. Stats.) to me known to be the person ._.......... who executed the I foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland Lundeen ---•.........................•---............................................... --- --rn. --- ----------------------•-.................. Attorney at Taw -----------------••---------........---•----•---........---..................... Notary Public .....--•..................................County, Wis. i (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration r are not necessary.) date: ..............1 19.........) �.._..,.,_ .:.....:.... ,:�__sue..,., 1t}...._.i H . z ' H a STC - 105 r a • H SEPTIC TANK MAINTENANCE AGREEMENT Ho St,. Croix County z a H OWNER/BUYER _'` �t� M j ROUTE/BOX NUMBE ` r� Fire Number . R j / �� .E! o�%tjJ.�+ .CITY/STATE `, b� � �, t ZIP� � / PROPERTY LOCATION:_/lj , _�L, Section, T A17 N , R -4:5�71 Town of , St . Croix County, Subdivision ` r �..�', Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior . to July 1 , 1978 . St . Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St . Croix County Zoning a certification form, signed by the owner and by a master plumber , journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- an 1 3 full of sludge and scum. t c 'tank is less than / essary) , the sep i g 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 W to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources . Certification form must be completed e St . Croix Count Zoning Office within 30 days and returned to the y g .. of the three year expiration date . SIGNED DATE St . Croix County Zoning Office P.O. Box 98f Hammond, WI 54015 715--796-2239 or 715-425-8363 _ Sign, date and return to above address . INSTRUCTIONS FOR COMPLETING FORM 115 - SRD - 6395 To be a complete and accurate soil test,your report must include: 1- Complete legal description; 2_ The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIit UM number of bedrooms or comi-nercial use planned; 4, is this a rlevv 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; R. PLEASE rase the abbreviations shown here for vvriting profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A sepias ate sheet may be used if desired; S, Make sure your bealchrnark and vertical elevation reference point are clearly shown,and are permanent; 9. t_,ompleie all appi opr iatel boxes as to dates, names,addresses, flood plain data, p elicolation test exemp- tior;, ii appropriate; 10, if the information (such as floor„ plaid,elevation) does not apply, place N.A. in the appropriate box; 11, Sign the form and place yol-O' a:ur€ent address and your certification number; 12. Jklake, legible copies and distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY VJITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st --- Sto€r,r (ovcr 10") BR Bedrock cob -. C',t)ohic 13- 10") SS Sandstone �qa_ G€.zvr l (undei 3") LS — L?rTaect rlrE s _ Sand HGL1,r __ Nigh &or.rmiwatei C{ a,s€a Pure -- flercnlatiun Rate; Mediun, ;i. nd ?1P ._ 1., Ali p, I' ire S:-?rare Bids 7 H r i({ ,rs, — c)"iwly `hand - :;rE,atE'r Than lw s, ....... `a"l'.0v LC)('nn L@SS Thai? ,R?'"I vv- < :lilt ulra,r fey (.�lutr L("e , %r _- R d s -- is 1 y CL.'[a} t_O£? , r%'i?f. -- ��€t 'pie's -' s?1tt:iy Ckay c1 s?-;tit Ct, r'i:1ck d _.... d,:,trrict -- pl r�*Ynr4:;i'lr 1-1V,!L — High v,ater le,,e[, Sly ale€lt l ar so7l Ie xzm-eS _ irtl. L ;titer 10 !�q� €c v.lasle d sp(r ? BM - Bench ,` wk VRP Veitical TO THE O VW� 1 h;. :;o' i E s' r¢r)_ll is-_he first lep in secltP"mq a sarli-pry pel"mit, The county or the Dep>a€`ttiierit inay YeC1rl('St 3 ��. .,, �"o) l ?.es*. ( ',C's# fioltl pvio( 'o of-rinif >suance, A ct'7tEviete .;et: of :)lam for the private tlld e p ecrnii, a}�n'll.�cii?�;t, "llus ;)e su )rnitte'd to 01c, appit:apriale local i4 ilhority ill ordElr to y pcn ";°tit n)1)St be oh I'Mcd and pf),Cecl 1p ior'to 'flc start of any eonstructi,)n, INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUST C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.0911)&Chapter 145.045) LOCATION: SECTION: TOWNSHIP OT NO.:BLK.NO.: SUBDIVISION NAME: &F /sF�/ /T N/R� E (o s- COUNTY: BUYER'S NAME: jMtAILING ADDRESS: rY USE Ji r 7 — DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: LE DES RIPTIONS: E OLA ON TESTS: Residence New El Replace RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) Es au ©S E CAS ❑U I CAS ❑U I IDS ❑U s - 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: C` Floodplain,indicate Floodplain elevation: 0 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B ( .7 fft a '8M s B- 1 // PS, 7 A 5 l s 7, c B- /J.9, 9s 6 i SkIs Zz s u B- y ' 'WS L-7 B- S' i 8 BLS 3•/' sns w B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER I PER INCH P- P- 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. SYSTEM ELEVATION 3 i t � I t 1 ' _ I E I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: to lqlf 7 5S: CERTIP1IcA1riON NUMBER: PHONE NUMBER(optional): 2 er. 0�3 4 3 -3 4 5- CST SIGNATUR DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — { r � Vs =W7C � S � � I oo �\ Z.�►WA C F J Ito N 1 ~ n IEws" — — — 00 a a i i I G s o � o X 1 J J o� M j O / Z w iz�j l J :00 a J � i 47 N� Z I J I � � y I: r ' o Yti� i NN I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS I N[10STf�'Y« DIVISION LABOR AND PERCOLATION TESTS (115) MADISON W 53707 HUMAN RELATIONS , „ (H63.090) &Chapter 145.045) LOCATION: SECTION: TOWNSHIP�ITY: OT NO.:BLK.NO.: SUBDIVISION NAME: fT N/R� E (o s' .� , �'o s COUNTY: eVP4EHZI1 B S A E: MAILING ADDRESS: 1-11 / c — USE 77— DATES OBSERVATIONS MADE NO.BEDRMS.:=IAL DESCRIPTION: PROFILE DESCRIPTIONS: A ION TESTS: Residence QNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system ONVEcNTIONAL:IMOUND:c ''ii IN-GROUND S STEcM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) �S DU O S �Y U J �U �S 0U 1]S �U "4 s 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: -ZAc T Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES 1 HE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- ' ,116 � .7 ,� � a B- 1 // S,� ! 7 � s F ' I " ' . D c B- /�S' �7S In / p v B- y B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH P- > P. < 6 > P-- P- S �� S T S 3 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 i III t 1 , f t I ' �.. tN _' I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: 7 $S: CERTI ICA ION NUMBER: PHONE NUMBER(optional): L 93;h dl 2 e,, o�.3 3 2 3 3 - s CST SIGNATUR DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.02182) —OVER —