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PUMP CHAMBER ` L
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: / '' Length: ��� Number of Lines:—.,-' Area Built:
�
/
Fill depth to top of pipe: --?5/
Number of feet from nearest property line: Front, Side, 0 Rear,O Ft
Number of feet from well:
Number of feet from building:
(Include distances on plot plan). L
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box 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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector: J
Dated: 4—J7�� Plumber on job: �[ XAAXrC"S r•/_i-
License Number:
3/84:mj
Z Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1 24.6k TOWNSHIP SEC. T N
2.
-RZ
ADDRESS �� ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT IT- LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IZ.HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
e
INDICATE NORTH ARROW
� n
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: T1� ,� Proposed slope at site: s 3
SEPTIC TANK: Manufacturer:. Liquid Capacity: ,.¢-(
Number of rings used: Tank manhole cover elevation: '2
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,0 Rear, feet
From nearest property line Front,O Side,M Rear,O � feet
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.BOX'7969 BUREAU OF PLUMBING
MAQISON,WI 53707
SW4, ,529,T29N-R19W MCONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number:
I If Town of Hudson ❑Holding Tank ❑ In-Ground Pressure ❑Mound
Lot 5 Country Hill
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
lLJ
Ardis Brandt R.R. Hudson, WI 54016
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. 11563 St. Croix 92551
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
l l`2 �9a F94 DYES NO DYES ONO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: LINE: LAIR INLET:
FEET FROM
DYES ❑NO ❑YES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROV
❑YES F-1 NO
OYES ONO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
LINE. AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) OYES 0 N NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO.OF ID ISTR.PIPE SPACING: !NO,VER INSIDE DIA. #PITS LIQUID
BED/TRENCH THE NCHES // RIAL: PIT DEPTH
DIMENSIONS / 2 S 2— �"' LN
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: TR. NUMBER OF PROPERTY WELL BUILDING: V NT TO FRESH
BELOW PI S ABOVE COVER E V NL E V ENDa PES' FEET FROM LIr S ! f� EiT
`j r • �,0V Z � 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.
1:1 YES El NO PERMANENT MARKERS OBSER VATION WE LLS
SOIL COVER TEXTURE
❑YES ONO ❑YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER. EDGES
❑YES ONO 1:1 YES ONO 1-1 YES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACI NG GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE UISTHIBUTION PIPE MATERIAL&MARKING
ELEV.: ELEV.: DIA.. ELEV.. PIPES. DIA..
ELEVATION AN D
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL'.
PLANS
OYES ONO I 1:1 YES El NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LRNE ERTV WELL: BUILDING.
FEET FROM
DYES ONO DYES NO NEAREST
e
�3
-03
Sketch System on Re tai in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
DILHR SBD 6710(R.01/82) Zoning Administrator
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever•necessat'y, usually every 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. Provides 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 8'%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
commomy known as the groundwater protection law. This change in statutes was the
result of cver 2 years of steady negotiation and public detate. The groundwater bill Ground Ater- .
included the creation of surcharges (tees) for a number of regulated practices which W;SCO €ri`S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water tha' buried �asure
is used is your building is returned to the groundwater through your soil absorption 6
system or the disposal site used by your holding tank purrper.
The monies ;oIie,,tec; through these : sr&i arees are credited to the groundwater find adminis-
te #e by $tee Department of Natural R--3sources. These funds a;,e u:,ed for rc!on,trari.• g. g'-our f�- f
contaminatlrr t in--estigations and estEtJlir.hm t of ;.tanda,ds. :=rU:Jr?dvvat�'::=,
pr. tec'.ng.
ir: 0
DAL SANITARY PERMIT APPLICATION COUNT
In accord with ILHR 83.05,Wis.Adm.Code STATJSANITARY PERMIT#
MEN—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 N NO
PROPE TY OWNER PROPERTY LOCATION
'/4, , N, R /9 E(Or
PR]61 R OWNER'S MAILING ADDRESS LOT NUMBER BLOCK MBER SUB IVISIO NAME
Cl Y TATE ZIP CODE PHONE NUMBER 7 CITY : w /- NEAREST ROAD,LA RE OR LANDMARK
D VILLAGE
11. TYPE OF BUILDING OR USE SERVED: - XA• V610 —70-0d 8
Number of Bedrooms if 1 or 2 Family Ls OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. X New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. Conventional b. El 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. X Seepage 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):
(/ Feet Private ❑joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Manufacturer' Steel Prefab. Fiber- Expp.
INFORMATION New xisting Gallons Tanks s Name Concrete strr cted glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank X I Li El
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.
Plu er' Name(Pr' t): Plu er's Signatur :(No amps) MP/MPRSW No.: Business Phone Number:
�✓
Plum is Ad r7ss(Street,Ci State,Zip Code): Name of Designer:
VIII. SOIL TEST INF RMATION
Cer'' d S it Tester )Name CST#
CST' DRESS(Str et,City,S e,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater [ate Issuing Agent Signature(No Stamps
Approved ❑ Owner Given Initial I f'\\ Sur ha�rge�^Fee _ /y
Adverse Determination / Ov. � 3 ;r_)d `� '
X. COMMENTS/REASONS FOR DISAPPROVAL:
') lay, R,aft �/ by hoary �',`T�h��ths
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
APPLICATION FOR SANITARY PERMIT
S T C - 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 T �
Location of Property AJ {� Section ,
T,2 - R W
fi?wnship lv
Mailing Address
Subdivision Name
Lot Number r
Previous Owner of Property .�JD 00
Total Size of Parcel
a
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes A— No
Volume and Page Number —:f34l as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
1. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, would be CertifiediSurveyys
deed description of the reviewing process. If the
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) eerti,jy that aU 6tatement6 on .th i.a joun are tAue to the best 06 my (ouh)
h.now.2edge; that 1 (we) am (ate) the owner(s) of the pnopeAty d"cAi.bed in this
.in6onmati,on 6onm, by vi tue o6 a wwmanty d ed neeonded in the 066ice 06 the
County Reg-i.aten o6 Veedb as 'Document No. ; and that I (we)
ptedentZy own the proposed s.cte bon the sewage pod 6ydtem (on I (we) have
obtained an easement, to run au th the above de6c i.bed property, bon the,
con,6tAucti,on o6 said system, and the same has been duty neeonded in the 06j.iee
o6 the County Regi4teh. o6 Deeds, ab Document No. 1
`SIGNATTURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DOCUMENT NO, j SL: BAH OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED REGISTERS 01"CE
$02 55 Q VOL PAGE4� ST. cRoIx Co.,
-- wis.lotn
Rec'd. for Record this
This Deed, made between ---- ................ day of June A.D. 1(;65
at 9:50 A.
i M.
----- ------
0 i.
----------------- --------- ---- -- ----- -- - �22�
--- -- •--•-------------•--...., Grantor, .. ,
�;� ` ',Conllel l
and._...Ardis._&.-Brandt_and_Tel a-B._.Brandt►_-husb-md-and
--•.__-_
----------Ailife--as--joint--tenants--------------------- ..................... ------ .
-----=----------------- --------------------------------------------------------------•--• • Deputy
-----------•------------------------------------------------------------------------------------••, Grantee, P Y
Witnesseth, That the said Grantor, for a valuable consideration__---- l
.....of_-cne•_dollar_.and__other__valuable__dmsideraticn--------------- iI RETURN TO� —
conveys to Grantee the following described real estate in ....St,___CrOix............ II
County, State of Wisconsin:
Tax Parcel No: _..----•------------------
Lot 5, Country Hill Subdivision in the Tbwnshio �_._....
of Hudson.
4WAN FE
row
5
EEE
This ------- homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And-----JDhn_.L....Rorvick._and_Llynthia.A.__ :bi:V±ck----------------------------------------
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
recorded protective covenants, easements, utilities & restrictions of record, if any.
and will warrant and defend the same.
Dated this ----------------� ' ------------ ----- day of ---- ---June----- -------------- ----••-•-•- -- 19...85..
--------(SEAL) ----- ---------------(SEAL)
----------------------------------------------------------------
v�
�
---(SEAL) ------• --------•-- ................ - -- • ----•------------(SEAL)
* thia A. lbrvick
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ••--_----•----•---- STATE OF WISCONSIN
-----------------------------------------
ss.
-------------------------------------------------------------------------------- St. Croix
--------- ---- ---------------- County. T1c
authenticated this --------day of--------------------------- 19.85_ Aersonally came before me this _---Z ......day of
-------- -------------------- 19$S,---- the above named
-----Jahn._L..__RDzvirk.-arid------------------------------------
* -----Cynthia__11__.ROr_Virk---------------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not " "_
-- - - - - ................
authorized by § 706.06, Wis. Stats.) =� h
to me known t0q.thL•pMV04, `yS..._. who executed the
foregoing in et ac� esdtge the same.
T-,t I INgUf1ENT AS DRAFTED BY
.________.GIG.\..Ld,C1L1.G7.,-__CYG�L•LLl__SC_�Q_..____._°______________ v�y� -- -.--1)M1 -----522
Seoand Street *-----��A.=_ ' ty_ _____________ ______
---------H d v-Wiscum sin------54416-------------------_ Notary Public -----St __Cr+O]30;----------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission, is permanent.(If not, state expiration
are not necessary.) date- ---------------------I-------- ------------------------- 19.........
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 1—1982 Milwaukee, Wis.
H
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STC - 105 r
a
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
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OWNER/BUYER
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP
PROPERTY LOCATION: (&) k, S:J 149 S ction,-29' , T��N , R_,,y W,
r
Town of ,a j St . Croix County,
i
Subdivision 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 pit 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
three year expiration. yo
I/WE, the undersigned, have read the above requirements and agree
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 Office within 30 days
of the three year expiration date .
r
DATE - /—k-
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 - SBD - 6395
To be a complete and accurate sail test,your rea>ort must include:
1. Complete legal description;
2. The use section roust clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms of commercial use planned;
. Is this a new or replacement syste€n;
S. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE c.liagram accurately locatir=g your test locations. Drawing to scale is preferred. A
sel)rarate sher:t may be used if desired;
8. Mal«sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
0. Complete all app€opriate boxes as to dates,names,addresses,flood plain data, percolation test exemp-
tion,if appropriate;
10. If 111-'e kr formation (such as flood plain,elevation)does not tapPly, place N,A,in the appropriate box;
11. Si(In 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 C h,1PLETIt N.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
tit Sic'no over 10") BR Bedrock
cola Cobble: )3- 10") `:S — Sandstone
gIr -- G rrs=rel (under 3-} LS -- Lirnestone,
�s Saari I-,€W High C;€o€ ndwater
I s - C.e-ca,sea Sand here - Pe!colation hate
1s fin, S--,r:ci E31rac _ s n idler,
is - Leary Sand >
C.r aicl Than
sl _- Saandy Learn < - I,oss Than
Loam bri - Brown
s€l Silt Loar-0 BI Black
ci Silt Gy — Lray
c Clay Loan ' - Yello7a
sc.l _.- Sanely Clay Loa€n R -- Ri,fi
siC i - Silty Clay Loran snot - Mc:t.t°es
Sandy Clay w -- t-vath
S€c — ilt", Clay' —
fff - ff_v"J, 'I,C3;a #,"fit
rc
c _ C"�a43 c;. -- «a"nlStor c�arese
P! - Pcat ,Fn — Many, n-rediuna
rs -. luck d — distinct.
HWL High water level,
Six perseral soil textures surface water
for liquid waste disposal 61`0 Bench Mark
VRP Vertical Reference Point
TO THE OWNER:
This soil te=st report is the first step if)securing a sanitary permit. The county or the Department may request
vei ificatiora of this soil test in the field prior to permit issuance. A €omplete sot of plans for the private
sFvvuge system and a pen-nit application must be submitted to the appaopriate local authority in order to
obtain a permit. The sanitary permit niusl he obtained and posted prior-to the start of any construction.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
DIVISION
INDUSTRY,. - -
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIQNS (H63.090)&Chapter 145.045)
LOCATION: SECTION: TOjWN�HIP/ ICIPALITY: LOT NO.:BLK. : SUBDIVISION NA
� � N/R V(or, •�
U TY: OWNER'S/BUYER'S NAME: MAILING ADD ESS:
C T /
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERC AL ESCRIPTION: I PROFI E ESCRIPTIONS: ER OLATION TESTS:
Residence XNew ❑Replace r�p (� '7 I
('S
RATING:S=Site suitable for system U=Site unsuitable for system —
CONVENTIO❑NAL: MC�U �.❑� IN-GROU� Pa�RE: SYS�T�-IN-FILLHO❑LDING® MENDED�SYSTE :(optional)
SS UU INS (LQ�J U S y/
N E:
It Percolation Tests are NOT require DESIG RAT I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: Floodplain indicate Floodplain elevation:
,�l,,
PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH tM, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- }
B- > -
B- >
B-
PERCOLATION TESTS nlaAr
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE ER INCH ES
NUMBER I S AFTERSWELLING INTERVAL-MIN. PERIOD-1 P RI P R
P-
P- s /1
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 ��
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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 rin TESTS ERE COMPLETED ON:
ADD CERTIF CATION NUMBER: PHONE NUMBER(optional):
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CST,9�GNA UR
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
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ry PAGE OF
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Cr0 S �C ' I01, o � /� 1, k ��
Fresh Air Inlets And Obebrvation Pipe
Q+-Approved Vent Cap
KfS� l
Minimum� 12"Above
ll[ij lfs-� d Final Grad*
20-42"Above Pipe _4"Cost Iron
To Final Grade Vent Pips
Marsh Hey Or Synthetic Covering
win 2"Aggregate
Over Pipe
Olsrrlbullon Tee
Pipe -io 0000
6"Aggregele lot-- rCoolng PerlorefeS Plpe aslay
Beneath Plp• Terminating At
6ouom 01 1111016111 PO5eD T tnal ``gr,A-c
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SOIL FILL
DISTRIBUT101.1 PIPE APPRJVED SIINTHETIC COVER
''--plATERIA� OR 9" OF STRAW
2"OF&G6REGATE -��� ,/ ORJAARSN MAy
(e'OFJ2-LIA' AGGREGATE
ELEV. o f FEET--..
DISTRIBLJTIOIJ PIPE TO BE AT LEAST INCHES BELOW ORIGIAIAL GRADE
AAIU AT LEAST ZO INCHES BUT 1.10 MORE THAtJ 42 11J04ES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXc/w^TIOP FRcM GAi&rdAL 6RAoF- WILL BE �— IAICHES
rMMUM gfPTM OF EXCAVATION fK01A. GRAPE WILL BE INCHES
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SI&MED:
LIC E W SE AIUMBE R:
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' D ATE:
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