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HomeMy WebLinkAbout020-1157-90-000 g C) } ` j & . ] & ( 0 \ . I » � . & � # i J � � } � 2 � § ) C I \ § 3 \ \ 7 ] f i % \ § E 2 m N / £ m S � B 2 2 \ S « ® § ® ) 2 7 / E 2 4) m 5 ' ° cl [ § c 0� � ƒ Q ) ` } ) k ) g - . CID 2 � J ~ � ; § ■ } # 2 k / \ / V) \ 2 j DLO_ \ 0\ n G \G I s 04 a a.. � � a R 0 j § \\ \ § i G g $ ƒ § e (D 0 0 3 \ § g \ E S $ » 2 2 J § ® o J CD 2 ± � 5 _ E N r = / f© \ ¥ a EL E E@ % CO / a [ ) c = / ® ¢ e . \ R ° r- 2 \ K ] 0 § § E i \ - § m 2 § G o 2 $ } ■ _ ® � k M ) k a 2 2 k ■ a CL z 2(D . o J a 2 � o � PUMP CHAMBER � t 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:eoy,ucsk:A',ph c( Trench: i r Width: Length: S Number of Lines: Area Built: . Fill depth to top of pipe: ]/i Number of feet from nearest property line: Front, O Side, (S{1 Rear,01't Number of feet from well: Z O Number of feet from building: / (Include distances on plot plan). SEEPAGE PIT Size: _ Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: ��/ Dated: Plumber on job: A l �J Z License Number: I 1 3/84:mj Form - STC - 104 M AS BUILT SANITARY SYSTEM' REPORT OWNER � OO�d TOWNSHIP ���4 �D)7 SEC. 2�° T 0'? N-R� ADDRESS �C�$ //KCQ�' �/.Nt(f ST. CROIX COUNTY, WISCONSIN SUBDIVISION ��f-A ((,O SLOT —ta (, LOT SIZE yew Vs 4C-a� PLAN VIEW Distances and dimensions to meet requirements of IIHR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S c o� Irnoo r�, l3_ 1h. B/4 � a,r E. lCTco/nd✓. zgxSV aYX3z 2D^ 1 N4 Se a7� 107 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 4& Ra �/ 4fi S F JO-1 ICo11 014-V m Elevation of vertical reference point: ,�b,o Proposed slope at site: 7�9 �S tee SEPTIC TANK: Manufacturer: (&)q j S¢r Liquid Capacity: in 0o qQ- , Number of rings used: Tank manhole cover elevation: 10 �- Tank Inlet Elevation: mil. (o v Tank Outlet Elevation: rJ910 Q-151 Number of feet from nearest Road: O O 7S feet Front, Side, Rear, / From nearest property line Front,OSide,�Rear,0 feet Number of feet from: well building: fbv+A-, (Include this information of the above plot plan)( 2 deference dimensions to septic tank) SEE REVERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS DIVISION LABOR&HU'YIAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING II P.O.BOX 7969 ++ MAMSON,WI 53707 SW%,SE�4,S2611T29N—R19W )M CONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: (lf assigned) Town of Hudson O Holding Tank O In-Ground Pressure O Mound Lot 26 High MEadows II NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Scott Moore 727 Laurel Avenue, Hudson, WI 54016 RE .PT.ELEV.: CST REF.PT.ELEV.: BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Douglas Strohbeen MP 5932 St. Croix 92498 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TA INLET ELEV.: TANK OUTLET ELE V.: W OVI ED LAB L PROVIDED OVER YES ❑NO DYES b(VO NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH BEDDING: VENT DIA. VENT MAT L.'. HIGH WATER LINE_ /� AIR INLET: ALARM' FEET FROM �YV\ /'mot//� DYES ONO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. ROVID DLABEL LOCKING OV IDED OVER ❑YES ❑NO OYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. AIR INLET RESH FEET FROM LINE (DIFFERENCE BETWEEN OYES ❑NO NEAREST PUMP ON AND OFF) LENGTH: DIAMETER MATERIAL AND MARKING SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LIQUID BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPES'ACING COVER PIT INSIUE DIA SPITS DEPTH TREUHES: TERIALt DIMENSIONS I NUMBER OF PROPERTY WELL BUILDING: V NTTOFRESH GRAVEL DEPTH FILL DEPTH UISTR.PI E DISTR.PIPE DISTR.PIPE MATERIAL: F P.O R. LINE. �/ � AIR L�j. BELOW PIPE�t ABO E ER. ELEV INLET EL V.E D. ^ el � FEET FROM I I 1U"}— o/�/ 0(P " / �L l NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES NO PERMANENT MARKERS. OBSERVATION WELLS OIL COVER TEXTURE ❑YES NO OYES NO DE=OVERTRENCH/ ED DEPTH O VER TRENCH/BED DEPTH OF TOPSOIL. SODDED F"""D MULCHED CEEDGES. YES ❑NO LEI YES ONO YES F-1 NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO DISTR. DISTR.PIPE UISTRIBU 710N PIPE MATERIAL&MARKING ELEV.: ELEV.: DIA.. ELEV.: PIPES DIA.-. ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS OYES ONO ❑YES NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. COMMENTS: FEET FROM LINE: 5 ❑YES 1:1 NO OYES NO NEAREST i 1�3 �° � c� 'z Sketch System on Retain in county file for audit. Reverse Side. sIGNAru TITLE' DILHR SBD 6710(R.01/82) % �' Zoning Adm inistrator 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 Iccation, 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 systc; ;�, 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; li. 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 13'/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; 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 8tei included the creation of surcharges (fees) for a number of regulated practices which Wiscor c'art's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried YeaSui, is used in,, your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. a T,e rnones ::ollected through these surcharges are crecited to the groundwater fund adminis- tF red by 'he 'department of Natural Resources. These funds are used for monitoring ground- T water, gr;ur dwater contamination investigations and es'ablishment of standards. Orourrdwater, it's worth protecting. S3D-6398(R.03/86) — J =ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code srA A�AR PERM# , I-)el r —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWNER ,y PROPERTY LOCATION ,5C_,0 Zt /,/voea-- SkJ'/a$,C- %, S 2Y,, T , N, R Z E(o PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER IBLOCKNUMBER SUBDIVISION NAME k iv Q- 2 (D ' h G oav W ITY,SS ATE r ZIP CODE PHONE NUMBER 89SG CITY / NEAREST ROAD,LAKE OR LANDMARK it4� �.L y0 7�S 3 (�• OO VILLAGE: 4-150,1 TOWN OF: W II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): Ill. 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. X Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. 9 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): PROPOSED(Square Feet): q r�I C / 3 � 3 � / 3'40 'Feet X^ Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank 000 / iv-1 3 d-> ❑ ❑ 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: 01 ^'► �' ` 4' 132 Z-1 3233 Plu Ier's Address(Street,City,State,Zip Code): f Name of Designer: ,A/e4.. /? t4 ^► s �► Gv'�g 4 � � /.1 eu f� � � lJccti VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# A S ; s'�'o A. t. PIN 1.5-197 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: ak rdl Ave- a Ao-n W=, o/ -7, 314-- S1 r/ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) ®Approved ❑ Owner Given Initial Surcharge Fee /�' k - �/ Adverse Determination " "vQ ' O5Qa �^' !u ' '� �" "�/ /-A'C 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 I i This application form is to be completed in full and signed by. the owner(s) of the property being developed. Any inadequaoies will only result in delays of the permit issuance. Should this development be intended for resale by 0�Mer/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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - i- - - - - - - - - - - - Owner of Propertq '�� Irk r Location of Property (/ ,5 , Section y_, T N - R y � Township �� • _____._. .. ... 1 Mailing Address �. � Le� Gil 1 1 Subdivision Name t GcJ S Lot Number �� Z Ot Y , Previous Owner of Property 1M.K p n Total Size of Parcel q2 4 Date Parcel was Created Are all corners and lot lines identifiable? Yes _ No Is this property being developed for resale (spec house) ? Yes - ' No i Volume and Page Number 4 Z-, 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 Nap, the the Certified Survey Nap shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - • PROPERTY OWNER CERTIFICATION 1 (We) cea ti•6 y that a t t e tatementd on thiA ohm axe txwe to the beet o 6 my (out) knowledge; that 1 (we) am (axe) the owneA(d f o 6 the pxopetty deal c i.bed in th,i a in6oAmati.on 6ohm, by viAtue o6 a watnanty deed xeeoxded in the 066tce o6 the County Reg.ieteA o6 Veede ab Voeament No. :Za 4( � ; and that 1 (we) pneeentty own the pkopoeed d•cte box the sewage po4af-,6y6tem (ox i (we) have obtained an easement, to h.un with the above de6cAi.bed pnopexty, box the consthucti.on o6 bai.d system, and the Game has been duty teeoAded in the 06 jive 06 the County Re94sttA 06 Ueeds, ab Document No. +) . SIGNATURE OF OWNER S GNA RE OF CO- NE OWR (IF APPLICABLE) a . DATE SIGNED DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA 424337 � WARF#ANTY DEED ---- ----- JlERS OFFICE T. CROIX Co., WIS, This Deed, made between ---�Z7._�I7.Y),.A....1�aXQxl..2'.X:L).a�"i.,,..,.. �E'�,CI. i�,r ���cord ale nn.A_.-.Waxoxl..--TruQtee...and.V_rce� 1a..M-....WaxQ.n........ His loth Trust-,-..V. Cc.ella..M._."Maxon,.-.Tr a us.te ,--.to...each--------------- day of T_rust---a-..one.._half._inter_es-t..as---tenants-_ in...QP=lMr, ®P g�"A'g: 19 87 and.... A. Sc-Ott--Pi;---Moose"-aricl""N�:rie'�ti3'-�:--•Moor-e----•-••------• •� ------"""""""" Ylusbaric aYid w�` --- s survi�tsrshiTs marital' ' r61-"6rt ."--------------•------------ rabl.r of owe ............... .............•. --............I Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... .-_-.Grant.or........................................................................................... _-_-- _—conveys to Grantee the following described real estate in ......,5t ---C r.Q ix....... RETURN TO County, State of Wisconsin: Lot 26, Plat of High Meadows II in the Town Tax Parcel No: ................................... of Hudson, St. Croix County, Wisconsin. E This _._1.. riot_............ homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And.....Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. Dated this ......... e11.t_l1________________________ A ril $ day of p - 19._.7... . . ... ........... - ......_._.._ SEAL ( ) •...U� k�L � 2��'�-(..........(SEAL) - - -• ''l1 * G enn A. Waxon * Vycella M. Waxon . ---...-•-.---•--••-------••- -------------------------------------------- ............. -------•-------- ----------------------------------------------------(SEAL) ..... ----.-(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) _G122111_-A. WaXOn�"_"_--_ STATE OF WISCONSIN Vyce.11a M. Waxon _ ....................................County. auth77/-�this _1 _..day of._April . 19$7 Personally came before me this ................day of .� 6--2 uZU CL �,C�'6l Gl� �- ✓ ---"-----•-------------------------"------, 19-------- the above named ------- --------------------------------- ---•---------- --------- KristinaOgland Lundeen -"-""-"""--""-"-""---•""--•---.._....."-----------------------------------•----- TITLE: MEMBER STATE BAR OF WISCONSIN ............................... (If not, ---"--""---""---"--""---"---".................authorized by y § 706.06, Wis. Stats.) to me known to be the person ............ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland Lundeen "-""""----"--------"---"--"--•----•""-"----""------•-----••--•..................Attorney at .......w ••............................. ... Notary Public ---- ................... County, Wis. (Signatures may be authenticated or acknowledged. Both Ali Commission is permanent. (If not, state expiration are not necessary.) date: ............................................. — ---- - -- - — _ -- - -. .19 _ *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTy nrrn RTATF-_L1-&-R._iVP RL!1j0L\i Cihl _ - z ` H a r ST C - 105 9 H SEPTIC, TANK MAINTENANCE AGREEMENT o St . Croix County z d a H OWNER/BUYER ROUTE/BOX NUMBER ��'7 Lct /ad Fire Number �— CITY/STATE /- L,Lfo wZ LIP PROPERTY LOCATION : ,) �, SF— 14, Section iZG T a�N , R , Town of#4 St . Croix County , SubdivisionW,,5/1 >5 JU , Lot number Z,6 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 {I 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 W to maintain the private sewage disposal system in accordance with H 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 � GTd7�L_ DATE �/ C � V 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 . INSTRUCTIONS FOR COMPLETING FORM 115 - SRO - 6395 y t 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; 1 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE use the abbreviations shown here for writing profile descriptions and completing the Blot plan; 7. MAKE A LEGIBLE diagram accurately locatinfl your test locations. Drawing to scale is preferred. A separate sheet may be used it desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates,names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. if the information (such as flood plain, elevation)does not aptrly, place N.A. in the appropriate box; 11. Sian the form and place yoclr 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. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cof.) Cobble (3- 10") SS Sandstone gr Gravel (under 3") LS - Limestone 's - Sand HGVV - High Gioundlivater cs - Coarse Sand Pere -- Percolation Rate med s - Medium Sand W -._ rNo11. Is Fine Sand Bldg - Building Is - Loamy Sand - Greater Than Sandy Loam � -- Less Than i - Loam Bn - Brov�n "sil -- Silt Loarn BI - Black si __ Sill G - ( ra 'c# -- Clay Loam Y Yellovv sc.l -_ Sandy Clay Loam R - ;fed sic! - Silty Clay Loam not - Mottles sc Sandy Clay vv/ with sic - Silty Clay J ff; -- few,finr", faint Clay CC - ccxrrmon,coarse rt - Pena min - Many, medium n; - ,ultac;k d distinct p - prominent HVVL -- High water level, Six gencral soil textilres surface vvater for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: s61 test rcapo,(_ is the first sr,:3rl it)ser°rrrinc}a sanitary pcarrvait. The county of the Department May reol.Iest ai}�,rr of finis sail tc t io 1he field prior %o i is rnii, issuance. A co.ropletea scat of plans for thc private: ar<d a permit application rnias, be, sr�bmi=ted to the' appropriate local authority in crder to or The san,tar,, rr.t,rnrt OW S? bP 01rMir4ed and pof sterl uJor to the start of ra'71y construction, DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY, LABOR AND PERCOLATION TESTS (115) MADISON W 53707 HUMAN RELATIONS - (H63.09(1)&Chapter 145.045) LOCATION: SECTION: T0WNSH LOT NO.:BLK.NO.: SUBDIVISION NAME: S0 1/E'/a .26 /T,�9 N/R/`j�lo ,� s�� ,2� — �l cad �s��dow ?� COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: / Sf. e`ro )9- Si4M / 1� e.- T�w� Br�nK �d. /S hov G✓�S. SYc�I USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PER ATION TESTS: Residence 3 zf yxlVew ❑Replace Il /f CZ v RATING:S=Site suitable for system U=Site unsuitable for system ?6- k y �g CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) Q S ❑U .©S ❑U is ❑U IEIS ®U ❑S 01 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: /U Floodplain,indicate Floodplain elevation: PR FILE DESCRIPTIONS BORING TOTAL( DEPTH TO GROUNDWATER444GHE•S CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) Of Ij B- j ,S .3` d�cc� > 7•S' ,.�,�� /s /.J- A-k e, /s yA I3n /s B- J-- 7S' A301 s A.2, DtxA, !.s s'o 10n /s B- o ' 17. P 14 . /. 09/ /S. .F D k An /_S_ G. - 4- /s B- y O' 9 .3 ' Xldmv 8.c , 0 B/ /• Y k All 1110 s 6 9.11/s/ B- PERCOLATION TESTS L DEPTH/ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES WA4E-o- AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD PER INCH y,3 n 3o a .Z /S' P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensio s i:`suit a so reas`,jn cate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the pl (�1a ��`Qw� es rface\�le, tion at all borings and the direction and percent of land slope. / SYSTEM ELEVATION 3•© j e G,cw € l E _ E 3 , F 1 € t� E E ) ' 0101 P3 O � ' 1C 1 r 1! us i��es •w O go 4 1 ------[__, 3 � s i i I 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: ADDR SS: //4ure / / CERTIFICATION NUMBER: PHONE NUMBER(optional):_qolf L CS T SI NATURE: -C7 DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. 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