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_1 A U a 0 (A U
JMP 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:
r
Width: �/ Length:_ Number of Lines: Area Built: ,�L�
Fill depth to top of pipe:
Number of feet from nearest property line: Fro t, Side, O Rear,O Ft 4�
Number of feet from well:
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
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, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: —�" Plumber on job:
License Number:
3/84:mj
'a Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER / — TOWNSHIP SEC ^ T�N-R W
ADDRESS �j� ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
OF
r8 '
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ,'//�
Elevation of vertical reference point: 11�9,6 Proposed slope at site:
SEPTIC TANK: Manufacturer: ?ijeT[ '" Fr�r � r Liquid Capacity: /b „l(19
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,Q Rear, f feet
From nearest property line Front,O Side, Rear,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
DEPARTMENTjPF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDI
LABOR&FiI rM^, RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOj 7969 BUREAU OF PLUMBING
MADISON,WI 53707
NE14, NE14, S28,T29N—R19W MUONVENTIONAL ❑ALTERNATIVE (ltate Plan I.D.Number:
Town of Hudson ❑Holding Tank ❑ In-Ground Pressure ❑Mound
Lot 33-34 Cedar Hills Estates II
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION
Mark Highstrom Route 1, Hudson, WI 54016 / a —''Q_& � /-3'r)
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No County: Sanitary Permit Number:
Calvin Powers, Jr. 1563 St. Croix 99021
SEPTIC TANK/HOLDING TANK: CdV94- '72
MANUFACTURER: LIQUID CAPACITY. TANK INLET LEV.. TANK OUTLE ELEV.. WARNING LABEL LOCKING COVER
N PROVIDED: PROVIDED,
G�Z
o�y,g �,'Z 3;1 OYES ❑NO ❑YES'( ❑ O
BEDDING: VENT DIA, I VENT MATL. HIGH WATER NUMBER ROAD: PROPERTY WELL BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
I OYES ONO DYES ❑NO NEAREST'
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY JPUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ONO ONO
GALLONS PER CYCLE: P UMP AND CONTROLS OPERATIONAL NUMBER!.OF '.PROPERTY WELL. BUILDING.JVENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO 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
CONMENTIONAL SYSTEM: 0•& ( GL•I' Q 11 _
WIDTH. LENGTH. NO.OF [ISTR.PIPE SPACING: COVER INSIDE DIA.-. #PITS. LIQUID
BEt) RIwNGH TRENCHES. MATERIAL: PI7 DEPTH:
NSIONS I �\
GRAVEL DEPTH FILL D PTH ID ISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER''OF PROPERTY WELL: 113 UILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELEV.INLET ELEV.END. PIPES LINE: AIR INLET
FEET`FROM
9 S 9 1.U NEAREST
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.
DYES 1:1 NO
SOIL COVER TEXTURE JPERMANENT MARKERS OBSERVATION WELLS
OYES ❑NO ❑YES
ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =F TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER EDGES.
[-]YES FIND 1:1 YES ONO DYES El NO
PRESSURIZED DISTRIBUTION SYSTEM:
x� WIDTH. LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER.
EFeN�t TRENCHES.
i}dMEiillfo
!.MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
��yy �p °ELEV.- ELEV.: DIA.: ELEV.. PIPES
0IJwT .IlRUI '.. HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
JNJITFQlti�' . PLANS
❑YES F-1 NO ❑YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUA+IitiER O PROPERTY WELL: BUILDING:
FEET F LINE:
❑YES ��1aNO ❑YES 1:11
If 4?
Sketch System on Retain in county,file for audit.
Reverse Side.
SIGNATURE: TITLE:
Zoning Administrator
DILHR SBD 6710 (R.01/82)
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERM.I?
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
Il. 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'/s 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 aba
included the creation of surcharges (fees) for a number of regulated practices which Wisco En`S a
cari effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure
is used ir' your building is returned t1-1 the groundwate°- through your soil absorption o
system or the disposal site used by your holding tank pumper.
a
The monies coile�:ted through these surcharges ate credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These fund's are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwatc y, _
it's worth protecting.
=13D-0398(R.03%86)
DILH SANITARY PERMIT APPLICATION COUNTY
In accord 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 PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFOR TION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 12 NO
PROPS TY OWNER PR ERTY LOCATION
N, R E(or
PROP T OWNt'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION IAA r
.+ All S1
CITY STATE ZIP CODE PHONE NUMBER CITY NEAR ST ROAD,LAKE OR LANDMARK
f ❑ VILLAGE :
II. TYPE OF BUILDING OR USE SERVED: DSO"` —�a OC
Number of Bedrooms if 1 or 2 Family R I�c(Specify):
Y
ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. 0 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. 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. 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:
(Minute per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): r�t
Co/ ' , Feet L Private ❑Joint ❑ Public
VI. TANK CAPACITY ##of Prefab. Site Fiber- Exper.
in allons Total Manufacturer's Name Con- Steel Plastic
INFORMATION xisting Gallons Tanks Concrete structed glass App.el�New
anks Tanks
Septic Tank or Holding Tank ",+_ XT ❑
Lift Pump Tank/Siphon Chamber ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation o^private sewage system shown on the attached plans.
Plum er's ame(Pri ): Plu er's Sign re: o tamps) MP/MPRSWW No.: Business Phone Number:
CS
Plum 's Address( reet,City,'S te,Zip Code): Name of Designer:
I_� I; ,4A71
VIII. SOIL TEST INFORMATION
Certif SY Tester(CST me CST#
Qe s 1.
CST's DRESS(Str t,City,Stat ip Code) l� Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ proved S Hilary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
A roved S rcharge Fee pp Given Initial i
�G G:Gov —
Adverse
Determination �J GU c� 7 /.�
X. CO MENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
1
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 J
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 1% Zj/ 1%, Section , T-.�)9 N-R� W
,�� r
Township
Mailing Address
!l
Address of Site
r
Subdivision Name C' �pr(Z iu
. Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yea No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number 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.
PROPERTY OWNER CERTIFICATION
i We) ceA ti.6y that a t t s tatementh on this onm aloe tAue to the but o6 my (owc)
knowledge; that 1 (we) am (ahe) the owneh.('s f 06 the phopenty dez ch i.bed in th.id
.in6o4mati,on boron, by vi tue o6 a waAAanty eed gecokded .in the 06hice o6 .the
Countyy RepAten o6 Vee6 a.$ Document No. � , and that I (We) pnebentty
own .the pnoposed site 6oh the 6e-wage dispoa em (on I (we) have obtained an
ea.dement, to nun with the above dedclri.bed paopehty, bon the condthuctc:on o6 aaid
sya.tem, and the dame had been duty neconded in the 066ice o6 the County Regi,6ten o6
Veeda, ab POcument No. )
SIGNATURE OI► owmw SIGNATURE OF CO-OWNER (IF APPLICABLE)
� Z
DATE SIG6D DATE SIGNED
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
427565 j ti 03PAGE
kiGISTERS OFFICE
This Deed made between ........................ --------------------------------- 7. CROIX CO., WIS.
Cedar Hills Development-,---Inc .
------------ ---------------------------------------------------- - ---- .................•................... Rec'rj. 4'Zr Record this 29th
------------------------------------ .............................................. -------------------------
--------------------------------------------------------------------------------------------------. Grantor, N&q- June A.D. 1987
and----_Rark--- ...Highstrom and Linda A. Highstrom,
- -- - - ------- -
wife---as and_ marita l
.a-1------- 1:301 P Ak
husband ai�d-
------------ --------------------------------------------------------survivorship
px!pp_erty----------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------, Grantee, behow of Deed•
Witnesseth, That the said Grantor, for a valuable consideration..__..
Grantor
-- - ------ ----
---------------------------------------------------------------------------------
St Croix RETURN TO
i
conveys to Grantee the following described real estate n ----------------------------------
County, State of Wisconsin:
Lots 33, 34 cedar Hills Estates II, Tax Parcel No: -----------------------------------
Town of Hudson, St . Croix County, Wisconsin,
s n o t homestead y.This ...................
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And........Grant-ar-----------------------------------------------------------------------------------------------------------------------------------
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same.
Datedthis ---------------2 6-th------ --------------- day of .......June---------------- -------------------- --------------- 19_81.
---------- /--- - ------------ ----------- EAL) ep -(SEAL)
L (�4" --------------------------
Dean R. Larson, President * C. Harwell, Secretary-
------------------------------------------------------------------ --------------------- -------- ------------------Trewsu-rer
--------(SEAL) ------------------------------------------------------------ -------(SEAL)
------------------------------------------------------------------ ------------------------------------------------------------------
AUTHENTICATION ACKNOWLEDGMENT
Sigmature(s) ----------Dean R. Larson-,--------------- STATE OF WISCONSIN
- ---------------------------
William C. Harwell ss•
----- ---------------------------------------------------------------------
authentic t d this 26..._day day of....��n 87 --------------------------------------County.
e ------------- 19------ Personally came before me this ................day of
------------------------------------------- 19.------- the above named
---------------------------------------- ---- -------------------
-----------------------------------------------------------------------
*-.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
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
KristinaOgland Lundeen --------------------------------------------------------------------------------
-------------------------------------------------------- -----------------------
Attorneyat Law *----------------- ------------------------------------------------------------
-------------------------------------------------------------------------------- Notary Public ------------------------------------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My 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 DEED STAT,E "IIISCON'SIN Wisconsin Ley
_;al Blank Co. Inc.
H
• z
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ST C - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT HH
St . Croix County z
d
a
OWNER/BUYER dYl21L -A(�Ns�V ✓�
ROUTE/BOX NUMBE j� Fire Number
.CITY/STATE ZIP
PROPERTY LOCATION:.4L_14, _14, Sectio%22—, T,:�?_N , R _W,
Town of 4AA,0<,e-y) St . Croix County,
SubdivisionC6Z4/L AILLS , Lot number 33
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists of pumping out the septic tank every three years or sooner ,
if needed, by a licensed septic tank pumper . What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix. County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978 . St . Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St . Croix County Zoning a
certification form, signed by the owner and by a master plumber ,
journeyman plumber , restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary) , the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. 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- ►a
ment of Natural Resources. Certification form must be completed
and returned to the St . Croix County Zoning Office within 30 days
of the three year expiration date .
SIGNED
DATE -7 ZZI S•-7
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 .
i
INSTRUCTIONS FOR COMPLETING FORM 115 - S D - 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. 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 HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASEL? ON SOIL CONDITIONS;
6, PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A �
s(iparate sheet may be used if desired;
£f. Make sure your benchn-rark and vertical c*levation reference point are clearly shown,and are permanent;
g, Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp-
tion, if appropriate;
tog, If the inforroation (such as flood plain,elevation) does not apply, place WA, in the appropriate box;
]1. Sign the form and place your current address and your certification number:
12. Make legible copies and distribute; as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS
Soil Separates and Textures Other Symbols
St - Stolle (over 10") BR Bedrock
cols Cobble, (3- 10") SS - Sandstone
gr Gravel (tinder 3") LS Limestones:
-s - Sar1d HGW - High Gioundvitater
cs - C,f,ar4e 4anc? Per - P,tccatatko€? €fat,
nse d s tt�ditwrnt Sand W
;, Finw Sand Bldg 8tli1d;rtc,
I - Loarny Sand -_ Greater Than
,it Sandy Loan-, < Less Than
Loarn Bn - Brown
,il Silt 1_oarn BI _, fllze:k
Sill G ,_. C,?,,;)
(, Clay Loam Y _ Yr;llca,.-
s - &ndy Clay Loam ? R ed
sic I Silty Clay Lo£arn root - mot ,os
spa _ Sandy Clay `err _... tw I it r
�ic ___ Silty Clay° fff __ f?w, fine, fain,
`C -.._. Clay ce -- r*,oarrrron t arse
13' - PCat mm - 10,'Wiy, nWdR,ifl)
n - lViuc;k d - distinct
p - p=ornine.n
HWL - High Gvater level,
Six gen,'ral soil textures surface water
for ligtrid waste disposal BM Bench Mark
VRP Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sani=ary perrnit. The county or the Department n1ay request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must be suErmitted to the appropriate local authority in order to
obtain a permit. The sanitai y permit roust be obtained and Posted prior to the start of any construction.
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INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS D SION
INDUSTRY, 1 C
LABOR AtJD PERCOLATION TESTS (115) MADISON WI 537907 9 53707
HUMAN RELATIONS
(H63.090)&Chapter 145.045)
LOCATION: SECTION: TOXNSHIP/ LITY: LOT NO.:BLK. .: SUB IVISION NAME:,/ ,
COUNT) O NER'S BUYER'S N ME: 11VIAIWIVGADDRE l
USE DATES OBSERVATIO S MADE
NO.BEDRMS : COMMERCI L DESCRIPTION: PROFIL DESCRIPTIONS:1PERCOLATION TESTS:
Residence �� �New ❑Replace.
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RATING:S=Site suitable for system U=Site unsuitable for system
ONVENTIONAL: MOUND: IN-GRO JND•PRESSUR_E: SYSTE -1 -FILLHOLDING TANK: EC MMENDED SYST M1optiona 1
ZS �U 0S S D-
[:]U EIS Ds our r f
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:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH 1�%. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
Z 1
B' 4 i 4 7
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7
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13-w 7 1 9, 9 7 / 7,1,',?
B- r
-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER10041 PERIOD2 PER PERID PER INCH
P- -3
Z�r-
P
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe w t 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 directioRiod percent
of land slope. ;� �
SYSTEM ELEVATION
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1,the undersigned, hereby certify that the soil tests reported on this form ere made by me in accord wit the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the test it pf my nowledge and belief.
[AD AME rin ^ ESTS WERE COMPLETED ON:
J 7
SS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
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DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
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PAGE OF
CroSS SZc_ 10 (1 o A Qco SYSten-)
Fresh Air Inlets And Observation Pipe
J: -- Approved Vent Cap
r Minimum 12"Above
Final grade
�N/V 20-42"Above Pipe _4"Cost Iron
To Final grade Vent Pipe
Marsh May Or Synth"c Covering
win 2"Aggregate
Over Pipe
Distribution —Tee
Pipe —~ 0 0 0 0 0
B"Aggregate
Beneath Pipe 0 Perforated Pipe Beloe
th
o —Coupling Terminating At
Bottom Of System
prp�USpl�
��eJ•.T 1 or1 ��/�
SOIL FILL
DISTRIBUTI0"" P'PE--7
APPROVED S4IIITFIETIG COVER
c" .c o �"-MATEItll�4- OR 9" OF STRAW
2"OF AGG 9 EGAIE -�� OR MARSH HAy
e
°
J70 F 1p -2�/Z AGGREGATE
ELEV. oFFEET
DIS't"R151TI0A1 PIPE TO BE AT LEAST INCHES BELOW ORIGIUAL GRADE
AIJU AT LEASTP-0 INCHES BUT AIO MORE THAI.I H2 IkICHES BELOW FINAL GRADE
MAMMUM DEPTH OF CXCAVAT100 Rom 0KI&VIAL 6KADC WILL BE Zs-i _ IAICHES
M1141MUM ®Ep" of EXCAVATIOW fKoM 0IKIG11aAL GR49E WILL BE �_ INCHES
SIGUED:
LIGEUSE DUMBER:
DATE : �� _ ^,• .7
v
170
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