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HomeMy WebLinkAbout020-1081-70-000 k \ jk \ ¥ c 3 \ 0 \ � � \ § R \ ) co ¢ 0 \ / \ � § k 2 -co c kf\ 2 ® cc M \ / �� M < F-0 � « ! CO � \ z E � z_ , § & � 0) {\ a m 0 R z § z :!t 2 ) . � k \ z E \ ] [ C; -� § / : G Q \ z � z \ .. z \ g k 0 \ . 4 c ) E £ ( 0 k 2 ° 2 r- I E _ ! m ■ ■ \ 2 \ § § § z -� £ : 2 a a a \ o B ~ ~ U) -1 u § § § ƒ \_ a \ k ) _ ° E CL � o % o - - 2 E 9 \ � a G 2 E i K q E § g/ B . Q , § f f d \ 6 ) §§ U) z$ 3 \ E £ o - w m £ / \o f § c z _ 2 f « « E § � = - - " IL » a 0. 2 � , c k k (L m k k k . i Parcel #: 020-1081-70-000 05/20/2005 04:28 PM PAGE 1 OF 1 Alt. Parcel#: 29.29.19.331 G 020-TOWN OF HUDSON Current 'Xi ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): "=Current Owner " GARY W&DEBRA K VINDAL VINDAL, GARY W&DEBRA K 790 CARMICHAEL RD HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): =Primary Type Dist# Description `790 CARMICHAEL RD SC 2611 SCH D OF HUDSON SP 1700 WITC I II Legal Description: Acres: 1.100 Plat: N/A-NOT AVAILABLE 9 P SEC 29 T29N R1 9W NW NW S 115.1'OF N Block/Condo Bldg: 585.1'OF W 417.4' Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 797/539 07/23/1997 782/536 2004 SUMMARY Bill M Fair Market Value: Assessed with: 48281 232,200 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.100 28,300 151,300 179,600 NO Totals for 2004: General Property 1.100 28,300 151,300 179,600 Woodland 0.000 0 0 Totals for 2003: General Property 1.100 28,300 151,300 179,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 121 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 PUMP CHAMBER 1 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: uaJ 0. Trench: I r Width: 1� Length: 3(o Number of Lines: 3 Area Built:(o`IY5q737 Fill depth to top of pipe: `f 2 Number of feet from nearest property line: Front, O Side, ® Rear,O Pt . /vim Number of feet from well: 12 0 Number of feet from building: �'o (Include distances on plot plan). SEEPAGE PIT Size: ,v� 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: N Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: 2C "'C2 ,.,.- License Number: 3/84:mj Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 5cz 41 101 /11 l- TOWNSHIP SEC. C_ T !�N-R/ W ADDRESS ST. CROIX COUNTY, WISCONSIN UQ e, <z SUBDIVISIONir LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM sy�t�,w E IV. = 9_yG /off" 5COL & %"_ /p (a-x i a00 i ' r (p D Z4 q .J 2pX y� � j)(ty �E1I INDICATE NORTH ARROW A BENCHMARK: Describe the vertical reference point used (�W C0 o -V- Elevation of vertical reference point: ©Q.0 Proposed slope at site: (D-3% Vj SEPTIC TANK: Manufacturer: U, t r 5 t✓ Liquid Capacity: 1o�¢ l Number of rings used: / Tank manhole cover elevation: 9rI. 2z:, Tank Inlet Elevation: Tank Outlet Elevation: i Number of feet from nearest Road: Front, Side 0 Rear, O � feet From nearest property line Front 10 Side Rear,0 / g feet Number of feet from: well `� building: for♦ 18��io„� S w Co, µQ,, o (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 REILATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 S29,T29N-R19W [CCONVENTIONAL El ALTERNATIVE ISlate Plan I.D.Number: IH assigned) Town of Hudson ❑Holding Tank ❑ In-Ground Pressure ❑Mound Lot 1 Carmichael Road NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE Sam Miller Route 1, Box 282, Hudson, WI 54016 10-d6- g7 a -3 o BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REP.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix 99045 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: c� 251'ES 1:1 NO ❑YES b2 NO BEDDING: VENT DIA.: VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ,^ ALARM: FEET FROM /� LINE Q ,r� OfU AIR INLET. ❑YES D4NO ❑YES AO NEAREST �CJ vim+ DOSING CHAMBER: MANUFACTURER. AMES: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: 1:1 NO ❑YES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP A ND 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 FORGE 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 DISTR.PIPE SPACING. COVER "JINSIDE DIA.. #PITS: IL IQUID BECflTREfYGH TRENCHES F M TERIAL: PIT DEPTH GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR,PIPE DISTR.PIPE MATERIAL: NO R NUMBER(,�F PROPERTY WELL: BUILDING: VENT TO FRESH BEL W,P,IPES ABOVE COVER ELEV.INLET ELEV.END. PIPE FEET FROM LINE A}I}��INLET f T 4 9`5 I/ / NEAREST 16 /� �v V6 71 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- ❑YES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS DYES ❑NO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED: CENTER. EDGES: ❑YES ❑NO OYES ❑NO DYES El NO PRESSURIZED DISTRIBUTION SYSTEM: tEOlTFTF.NGIi WIDTH LENGTH LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: . MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.: ELEV.: DIA.. ELEV: PIPES. DIA.: I I.kVATTtyN A��D t IT ON,',HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED " PLANS: OYES 1:1 NO i DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS NUInB`R OF LRIOE ERTV WELL: BUILDING: FEET` a 30 YrEsQ ❑NO ❑YES NO N115 91 I ' � 9 Sketch System on Retain in county file for audit. Reverse Side. SIGNA RE'. TITLE: Zoning Administrator DILHR SBD 6710 (R.01/82) f 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 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; II. Type of building or use served: If public is checked, iidicate 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 CILHR; 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, ceri:ification 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 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 06r- - included the creation of surcharges (fees) for a number of regulated practices which Wisco it's a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure' is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. Q The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) SANITARY PERMIT APPLICATION COUNTY �DILHR In accord with ILHR 83.05,Wis.Adm. Code C�dc STAT SANITARY PERMIT# V9d -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 X NO PROPERTY OWNER PROPERTY LOCATION so-'m Irn�� ��r /,va 4 '/4, S T , N, R141- E (o PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME k --A-- Z, G ,/crve- CITY,S ATE ZIP CODE PHONE NUMBER CITY J NEAREST ROAD,LAKE OR LANDMARK / VILLAGE: 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.;K 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) I 1. a. A 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. X Seepage Bed b. ❑See a e 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): PRO POSED(Square Feet): bpr C 60 97- /��g 5 7 7— �° Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in aal lons Total #of Prefab. Fiber- Exper. structed INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks T� Septic Tank or Holding Tank X 00 �di Ste.✓ .ICJ 4:F:FH 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/M RSW No.: Business Phone Number: M .X13 Z- 41 7 32- 3 3 PI ber'S Address(Street,City,State,Zip Code): Na of Design 111 In1� _L7L :c.k VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Cod ) Phone Number: La_4,_r d.,1 / 15' IX. COUNTY/DEPARTMENT USE ONLY f ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Id Approved ❑ Owner Given Initial ' / I' j$y�rcharge Fee Adverse Determination �/ V r 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 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 .S¢ Location of Property Section a4? , T a �F N-ROW Township Z&A®/2 Mailing Address Address of Site Subdivision Name _��i �,' �a. / �Sai�-i 47411 Al-e- A-1 J . Lot Number 47 Previous Owner of Property K; aAk k Total Size of Parcel �,r7<�� 5 Date Parcel was Created 7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 2 and Page Number s3 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) c¢n ti.6y that att .s.ta tementa on this foAm cute hue �o the be�sx o 6 my (oun) hnawt¢dge; that I (we) am (cute) the ownen(A 06 the pnopen.ty de�schibed in .thiA in6o"ation 6onm, by v.ihtue o6 a waAAanxy deed neconded in the 066ice o6 the County Reg-i,6 ten o6 Veedts as Vocument Na. 2 Z ; and that I (We) pneeentey own .tlie pnoposed bite bon the aewage duspFs- dyes em (on. I (we) have obtained an ¢aaemen.t, to nun with the above deacA bed pnopeJcty, bon the conAtAuction o6 chid d y,6 tem and the dame has been duty neconded �.n fleed6, ab floeum¢nt No. y the 065.cce o6 the County Reg�azen o6 �f Z 72-0 Z 1 . SIGNATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) . DATE SIGNED DATE SIGNED l ��� .. o. � �' : � .� . ,. � � ,t ,: J 427202 8 PA,E 5,16 Document No. WARRANTY DEED REGISTERS OFFICE ST.CROIX CO., WIS, _�c'd. icr Retard this 19th Richard L. Schwenk and Caridad A. Schwenk, of _June A.D. 19 his wife*,* James R. Schwenk and Mary Jeanne -- 87 Schwenk, his wife , and Joann E. Carlson, a 3:45 PjAd resident of Minnesota, **residents of the Phillipine Republic, grantors, w M DoWe convey and warrant to Sam E. Miller, grantee the following described real estate in St. Croix County, State of Wisconsin: Tax Parcel No. The south 115. 1 feet of the north 585. 1 feet of the west 417. 4 feet of the northwest quarter (NW 1/4 ) of the northwest quarter of section twenty-nine (29 ) , Township twenty-nine ( 29 ) north, Range nineteen (19 ) west This is not homestead property. Dated this 10 /A day of June ,1987 (SEAL) "Q. G� aa&(SEAL) Richard L. Schwenk James R. Schwenk SEAL Caridad A. Schwenk Mary Jeanne Schwenk L' _6 '�'- &lz/ L " (SEAL) JoAnn E. Carlson ACKNOWLEDGEMENT MA SF STATE OF WISCONSIN �� S.S. FEB Marathon County Personally came before me thisf� ay of June , 1987 the above named James R. Schwenk and Mar Jeanne Schwenk, his wife , to me known to be the persons wh executed the foregoing instrument and acknowledge t e same. / KAV`E ZENNER Notary Public SUte of Wisconsin Kaye e er Notary Publ ' , Marathon County, Wis. My commission expires Feb. 10, 1991 June 10, , 1987 STATE OF WISCONSIN S.S. St. Croix County Personally came before me this day of June , 1987 the above named Richard L. Schwenk and Caridad A. Schwenk, his wife , and JoAnn E. Carlson to me know to be the persons who excuted the foregoing instrument and ,,acknowledge the same. ,,, C y b ' S7, , k,c .GJ ;n 1u M inn Notary Public, 1 UO1�C':;_ u� Wis My commission NpAc;y-N" *"s , 1Cicio This instrument was drafted by Hugh F. Gwin H z En H • a r STC - 105 a , H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a H OWNER/BUYER—<&M- ,;r2 ROUTE/BOX NUMBER A-, � O X 2 8'z Fire Number CITY/STATE 17l����/7 Gl/� ZIP S7O�Gv PROPERTY LOCATION : /f k, ��� Section 1 T K N , R� Town of &/'.50/7 , St . Croix County , Subdivision , Lot number 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 , I 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 H three year expiration. o E z I/WE, the undersigned , have read the above requirements and agree (, 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 . SIC DATE -7 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 . DEPARTMENT OF, REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY P•O. BOX 7969 , y MADISON,WI 53707 LABOR AND PERCOLATION TESTS (115) HUMAN RELATIONS %. (H63.09(1)&Chapter 145.045) LOCATION- SECCTION: OWNSHIP/MHIW6+pA1.LF ul OT NO.:BLK.NO.: S B DI VISIO N NA — •s t a_/ CAI t7 i/4 w1�4 /T�9 11/11 f9 R o u d s ME ors ? COUNTY: OWNER'S BUYER'S NAME: MAILIN ADDRESS: /10V USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRI TION: I'Z R FI -DESCRIPTIONS: PERCOLATION ESTS: Residence All ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system (o 6 /" •-� �g ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEMaoptional) ®S ❑U I ®$ ❑U ®$ ❑U ]$ O cn vim.f' If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under 5)(b),indicate: /v /4 Floodplain indicate Floodplain elevation: PR FI E DESCRIPTIONS BORINGI TOTALI DEPTH TO GR U DWATER-RiGI Ire& CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER IDEPTH-4-W. ELEVATION OBSERVED L51.HIGRE—ST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- at S/ B- 3 j-' 72, 1 A4,Ae 7 �,�� , 7 lsi 7,o s AT lot g- PERCOLATION TESTS DEPTHS WATER IN HOLE TEST TIME DROP IN WATER LEV L-IN HES RAT MINUTES EST r MBER IDJCId1iS AFTERSWELLING INTERVAL-MIN. P RI D 1 P I D PER INCH / . Q•3 ' a 3 0 G 3 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. $/S J0 s '?6*1 /C" 'z-q 6n g V--5, 10 SYSTEM ELEVATION . 9Y. 6 i s . _ a t4t i E �e_�o . _ +_- 7- f2 ---- __� -` TN Q , Q Px� 83,!R( C, . 0 Q I 0 E -.f, -LIre- I ° \ S/ ._.__...___ cc 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 ata recorded and the location of the tests are correct to the best of my knowledge and belief. t/' fly /dr .3 B ` iv — /'-[:lam fv. G , 'uce Owl '", e'l wd. S7� S%dL o<, o, 7fG-� r NAME(print): TESTS WERE COMPLETED ON: ADDRESS: / CERTIFICATION NUMBER: IPHONE NUMBER(optional): CST ATURE. C DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — x ; oa p p v► v� - q LA In V) r _. P P A ip LP r � ¢ LI P .0 e- N ID D ` � O so r �bo w -1?, Z,r -v fi F- -4- -- Vj v+ P � N f E4J 7'-1p elm ��Jr Lo LA V tA 11 :� r CCA i