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HomeMy WebLinkAbout020-1151-60-000 o ; C) 0 bs ~ 01 h o o � I � I c I I N � N � j I A � I I 0 c z 7 m I 3 � I a M I CD r Z Li E o E G z � a m rn w I N H fn j O O z c +r .- y - !i 0 f% H a- Z c E v Cl) N c rn m C a' a a N o c p m Z m 0) O 0) Z W m E O � I C ` C :0 N N Q C .O c o a a LO o 0 00 y- 000 Z aaa CL •� � 0 U) m J V o T 00 CO_w � O y � iz: N 0 � " Q O O M N a m rn o N m � a O H c O O c ^ d j N O c0 O 0) O r O N O A O C N O N Vfn M W _ N ~ O v 00 Z I� ` N • 7 N 00 O O U O p N 2 = 00 O z C H �' fn V A = E cd IL EL 0 EL � a CL 75 rr`w1v E c i c 2 _1 A c°� IL 'o 0 (n0 I r 5 f PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distac ion clot plan). HeaeeR .9,J - 95 SOIL ABSORPTION SYSTEM Bed: V TIwp h7 "V a M 6 4 , '� .g 3 Width:_ Length: Number of Lines: Area Built:-0 - Fill depth to top of pipe: Number of feet from nearest property line: Front, Side, ( Rear,0 Ft . Number of feet from well: Number of feet from building: 3V� (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 s y terns? 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: i Inspector: Dated: Plumber on job: License Number: 3/84:mj l r ti Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S��N � � �S TOWNSHIP H UJ S C)!L/ SEC. T Q 9 N-R�1� ADDRESS I -Box (989 ST. CROIX COUNTY, WISCONSIN st boa ash t�JIs, SUBDIVISION %610)1_11-Ai LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH,R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a � Be1P,oory', NOME, ­ 3W— / �r , d x � (o%� w od a I � 19' INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used F_tli ost IIik WO" To Elevation of vertical reference point: ) 00, 0 Proposed sloe at site: T SEPTIC TANK: Manufacturer: P-,z K $ Liquid Capacity: iGU i Number of rings used: Tank manhole cover elevation: f Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side, Rear, O feet From nearest property line Front,0 Side 10Rear,& feet f Number of feet from: well 53 , building,: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) _� _ —_ j CFF RFXIFAgF- gTnV_ DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR,&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION r P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 SE, SW, 29, 29, 19W MCONVENTIONAL F-1 ALTERNATIVE State Plan I.D.Number: IIf assigned) Town of Hudson ❑Holding Tank ❑in-Ground Pressure ❑Mound Lot 15 Presidential Estates NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPE TION DATE: Stan Hanks Route 1 , Box 688, St. Joseph, WI 54082 — I_g 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: Richard Hopkins 1059 St. Croix 88473 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET EV.: TANK OUTLET ELEV.: W FINING LA L LOCKING COVER P V DED: PROVIDED: t YES ONO ❑YES O BEDDING: VENT DIA.: VENT MA NIGH WATER NUMB R OF ROAD: PR PERTV WELL: BUILDING: VENT TO FRESH ALARM: AIR INLET: FEET FROM LIN / r ,._ DYES NO \ DYES NO NEAREST /i ✓ DOSING CH MBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDEO: PROVIDED: EYES ONO DYES ENO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF JR N E ERTY WELL BUILDING. AIR INLETRESH (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA. nP1T5 LIQUID BED/TRENCH TRES MATERIAL: PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE IDISTR.PIPE MATERIAL. NO I TR, NUMBER OF PROPERTY WELL: BUILDING: V NT TO FRESH BELOW PIPE ABOVE COVER: ELEV.INLET ELEV.END } . PIPE FEET FROM LINE. r� .N AIRN)L,ET. 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. OYES 1:1 NO SOIL COVER TEXTURE'. PERMANENT MARKERS. OBSERVATION WELLS ❑YES 1:1 NO ❑YES 1:1 NO DEPTH OVER TRENCH IBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. F-1-1 ED SEEDED MULCHED CENTER: EDGES: YES 1:1 NO ❑YES 1:1 NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV.: DIA.'. ELEV.. PIPES' DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ❑NO - DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LINE PROPER WELL: BUILDING: FEET FROM O (� DYES 0 N DYES 1:1 No NEAREST 0 Sketch System on f t 1 y� retain--irr wpnty file for audit. ReverseSide. f) "u# %' TITLE. GNA -- .� Zoning Administrator DILHR SBD 6710(R.01/82) i Thomas C, Nelson 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 syystem, or type of system; 4. Changes in ownership br 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 owners name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/z 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 I 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 aft' -- included the creation of surcharges (fees) for a number of regulated practices which wiscor4in& a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reaSi3re 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 pur .;per. 0 Thy monies colle;teti through these surcharges are credited to the groundwater fund adminis- tere,11 by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, "'s wort'-: protecting. SBD-6398;R.10M(3) SANITARY PERMIT APPLICATION CO u TY � 51LHR In accord with ILHR 83.05,Wis.Adm.Code C 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 INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES [54 NO PROPERTY OWNER PROPERTY LOCATION S ' N 5 L %5 '/4, S T N, R E (or)W PROPERTY OMER'S MAILING DQRESS LOT N BER BLOCK NUMBER BDIVIS�O NAME /( IUD �—.. CIT ,ST E ZIP CODE PHONE NUMB R CITY NEAR S LAKE LANDMARK AD 0 37 VILLAGE:' ILLAGE: II. TYPE OF IL ING OR USE SERVED: Ilk Sp Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): SIN VtbLtONA &Ct 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. VxConventional 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. ❑Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUI ED Square Feet): PROPCE Square Feet): 3 (01� `p 487. 9a Feet X Private ❑Joint ❑ Public VI. TANK CAPACITY ##of Prefab. Site Fiber- Exper. in allons Total Manufacturer's Name Con- Steel Plastic INFORMATION New xisting Gallons Tanks Concrete structed glass App- Septic Tank or Holdin Tanks Tanks Tank dd� Ljee Ks FL--R—. ❑ Lift Pump Tank/Siphon Chamber ❑ I ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Pr'nt): Plumber's Signature:(No Stamps) kWMPRSW No.: Business Phone Number: r P u e 's Address S eet,City te,Zi ode): N 'of D signer: IZ °� 0 o VIII. SOIL TEST INFORMATION Ce 'fied Soil T ster(CST Name CST# 1 CST AD RESS(Street,Cit ,State,Zip de) Phone NUwber: X34 d SO 0"I S c Z7 IS ) X" IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) ❑Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination / o.00 �V,Q© a / /,��'1� d W.64� r mc 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 v AI'1'I, CW1 1014 V(W SAWITAItY PERM` T S '1' C - 100 This application form :In to be completed in full and signed by the owner(s) of the property being developed. Any inacloquac-lcs will. only result in delays of the permit issuance. Should Lh-is duvelopiilent 'be .hit(!nded f-or.resale by owner/contractgz1 ("sped ; house"), then a second form uhould be r'uLlIkied and completed when-the property is s n, sold and submitted Lo LIr1n of I.'.Tca wltli Lhu appropriate deed recording.' - - - - - - - ._ - - - - - - - - - - - - - - - - - - - _ - , Owner of Property J 'j�ICN � , Location of Property .S(L .Sw ;r;, Section - ' T N - R l9 W 1 I Township Mailing Address Subdivision Name ----l����S/e��iYT�� a7`°.s Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created 9 Are all corners and lot lines identifiable? des No f`a Is this property being developed for resale (spec house) ? 4--Yes No Volume _( and Page Number �3 as recorded with the Register of Deeds , 1 t 74u, INCLUDE WITII THIS APPI.,ICATION ONE OF T11E FOLLOWING: LN J I Warranty Deed 2. Land Contract SF'• 3. Other recordi.nge filed with the Register of Deeds OfficeE� 4A}yr� } In add 1.Lion, a cert:a_I' I nil aiirvoy, i l.' nv,r l 1 111=1 t,, would be helpful so as to avoid delays 1 r r' c r I C : 110 ,It1n,I ,Ir'ur.r l LJon ref:urences to a Certified Surve Of the r.cv .ewl.uT, I a t G, u11 . I ( Map, the the Cel'L: I f I,:rr) Iltll`vt,y 1,1+11, 1111111 1 n I ru, Iitr roquir.ed. V1 CI KIT f VI CAT ION I ctlttE6 y ,tfia.t. all(' c,i1 111.1- hWtm air.e thue. to .the bm t o6 my hnowteclde; Bia.t I i--Ml- rain .the, t'nU,tclr_( 06 the p/t.opehty debcAi.bed in •th,i� in6onrrrati.on i6mm, bit v,01 tue. oK ca to(VI-rttir ty deed neconded in the 066ice 06 V e County RegLten o6 Ot vdi ra.s 0oo.mw,►a.(: No. _. 7,� and that T p4Uen.tey ours :the �)1t0p0,5t:d e.11C 6011 .0W set(mg, rtU- oea ey.te,n (on I (we) have obtained an e"ernen.t., to htu1 wi.Lli .?he obove desc& .bed pn.opeAty, bon the' F 1 con,6t/uaC.60Y,, 06 611-id 41/61""111, r(11d .the. lIonw has been duty ,L' corded tin the 066zce 1 r. , o6 the CounA y Reg.i,s t.oi 06 Ve ds, as Uuct(uneil,t No. SIGNATURE CIF OWNER SIGNA'T'URE OF CO-014NER (IF APPLICABLE) DATE SIGNED 1)A'T'E SIGNED �. ����u,fit .�u:l't.`_•�. DOCUMENT NO STATE BAR OF WISCONSIN—FORM I I I' WARRANTY DEED M ^ 1'I'''" c� p THIS SPArE RESERVED roR RECDRnING DA1A ! i 16Jw V _��3� OL 635 PACE338 1 - i I� This Deed, made between' .3arrell,.R_,A.ew15__-_._-,-_„- 'REGISTERS OFFICE 1 --.....•....----- .............--•--•--••-----• ST. CROIX CO., WIS. ...........................-----•............... ..................-......••-.......-------------- .......................Grantor Recd. for Record this 14th and_....S-tan.J 1a nks................................................................................... day of Sept. 'A.D. 19_81 I. ........... .... at 11 !45 ---•-- Grantee, • `` Witnesseth, That the said Grantor, for a valuable consideration_Qf R"61w of DMde One Dollar••and_•other-_val-laabJ_e_.consi-derat].4ClS........................ conveys to Grantee the following described real estate in t,__. R URN To County, State of Wisconsin: !I Lots #12, #13, and #15 of Presidential Estates, a Tax Key No. ...................................... I I' subdivision located in SE4 of SW4 of Section 29, T. 29N, R19 W, Town of Hudson, i St. Croix County Wisconsin. ii I TRA.NSFUR FEE This ....i s....not........... homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And.....Darrel 1 R. Lewis ------------------------------------------------•---------•-•----••-----••----- •---•••-------•-------•---••--••---- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except D none and will warrant and defend the same. I ' 25th August � Au ust Dated this ------------------------------------------------ day of ------ ------- 19_A1-i i ------(SEAL) .---•--•--••- (SE AL) AL) i I Da rell R. Lew s -------------------------------------------------------------------- --------------------------------•---- -- ` ---.--•------- -------------------------------------------------- I i ----------(SEAL) ---------------------------•-------- -----•-------------------------(SEAL) • ! I; AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this•___ ____________ day of STATE OF ' p`f 19•--•-•-- Minnesota ss. Washington • --•..................•---•------._Count y i ---•------------------------- ------------------------••----------------- Personally came before me, this ..... .....ZSth `'” of I . t;>t r pliC�USt............... the above named r.....,?.!Ipt TITLE: MEMBER STATE BAR OF WISCONSIN --------••-•............................... •---------.=-----,: ..... . Darrell R. Lewis = :' 't (If not, ------•----•-••----•---•-•---------------------------- ,._..._.. t....Ic ------------------------------------------------------------ authorized by § 706.06, Wis. Stats.j ------- 4.. • '_ THIS INSTRUMENT WAS DRAFTED BY to me known to be the person .... wvho"exWted the foregoing instrument and acknowledge thdt'slathe. ............................... .'� ha Z ..._ '.! - ............................................................................. (Signatures may be authenticated or acknowledged. Both Notary Public . ( _ ��E1 ...........County, %-i oMZ h are not necessary.) My Commission is ermanent. (If not, state expiration date: ._: t���-- .-- .................... ..., •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—1977 Milwaukee, Wis. (J01,3$980) a En x S T "C - i05: r 'r x <Y •s ," H SEPTIC TANK. MAINTENANCE, AU It GEM EN I', r1 0 St . Croix County.' z OWN EK,{ 't`*ltS ROUTE/BOX-NUMBER Fire Number CITY/S`1AZE L,9 1P r PIt0PEit1Y LOCATIUN :_,r3 4, ISe'c tiun" :Down of .St Croix County t Lot number <. Subdivision �t��✓e�vfcc�CCs�a 1•��� f _ Improper use., and ,maintenanee of pyour septic syste,,u co_u1d ..resulC in ' ` its premature• failure ;to handle 'was"tes . Prue er maint`enaitce -con ' } sis.ts' 0.f ;pumping .out t•h`e sept�igtank every ;three .'years or`> Soonet, � kY „... �. �t , if needed ; fby. a " licensed :s'� ptl�c rt°ank= iuu,Ler .` What yti'u p"u,t i'n'to � T the s-ystemcan affect .t-he -Cunction ' of, thu sul)�lc ',rank as 'a treat = meat stage: In the waste disposal system St Croix, County , residentsf�`iiw be uel:igiL)1e to rec:elvu a b:raaE, -.^. , Nt a .,naximu,n;Yif 60/ "of thh` cost of rep{lac�mu�l of �afail;inb `Syste►n;�� which wasin ,o{�erationa;prio" u1y1 ; '1y78 ' S'[' �('r.uixGourity , ` i ^t e`,"ru{gram `°�`n' Au �u t of 81'980 with' tli"e rc c`u�.'r meat : tha,Q.q aceep1.eU ChiSd,1I b .f b $ l Tr! C uwtiers of " 11—ncw ""systems �a .r a V keep `their Sysyt ms pxoperly r< ti .�» � Ill a 1 ll t a 1 Il E,d The Pr.uperty .owner agree'S t�tsutimit to °St ,Croix ;Couuay 'Z -to a .. certification;`form, signed,,:by tite owner `and by a master plu,nber , l journeyman plumber , re"stricl4�d�li�1.u►nber ui a ;licensed pumper ,veri v, Eying, that (1)` the >on sLte wastewater ldi`sposal systeui is�an proper- operating 'a ncl,itioofa6d (2) 's t rklnspection and pum`{iin> �'(�f 'nee essary) , t,he: septic an is. less than `•1 3 , full of sludge :Nand" scum Certifica"Cion,,f.orm will be serf[ approxiwately 30 ;days; prior to three',year' expiration �I � o } L/WE ; the ,,undersibned ,;:" have` ceadr tt?e above requirements and " agree, �, to ma intain<,the private sewa};e disposal system `in' arc°ordance with ` H the- standards `set forth, herein; as `set .,by the "Wiscons"in':Depa,rt ►o nrent of Natural .itesources Cer.tif� cat;Lon form "must be ,completed T z 4d and'e returii'ed to, the St .` Croi -6 nty-k2bl 'zng .Off ice `w,W n x30 days " Y ' of the three :yca•r. expiratio;n� a.tey, i t ' r y i p - � SIGNED xI ' C V' ?, g,*,r s�D Al E �,. r St . C1�oix :C ,unty Zoning Office'`, P.. 0 E•o x 98 Hammond WI 54015 715-7S:6-2239 or 715-425-8363 Sign , date and return to above 'ad�d�ress uc � 3~ fi}�,�,,W 1'P1' � � � 1. :aS x i3 �xvr $ INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 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 BASED 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 separate sheet may be used if desired; 8. Make scare your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. 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 riot apply, place N.A. in the appropriate box; 11. 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 - Stone (over 10") BR - Bedrock cot) Cobble Q- 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone "s - Sand HGW - Nigh Groundwater cs Coarse Sand Perc - Percolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is - Loarny Sand > - Greater Than sl - Sandy Loam < Less Than *1 - Loarn Bn Brown *sil - Silt Loarn BI Black si - Silt Gy - Gray #cl - Clay Loam Y Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot Mottles sc - Sanely Clay w/ - with sic - Silty Clay fff few,fine,faint C Clay cc; cornmon, coarse pt Peat mrn - Marry, medium rn - Muck d - distinct p - prorninent x HWL - High water level, Six general soil textures surface water for liquid waste disposal BM - Bench (Mark VRP - Vertical Reference Point Y� TO THE-OWNERi This soil test report is the first step irr securing a sanitary permit, The county or the Department rnray request verification of this soil test it) the field prior, to permit issuance, A complete set of plans for the private seavvac;e system and a permit application must be submitted to the appropriate local authority in order to obtain a permit.The sanitary permit must be obtained and posted priW to the start of any eOnstructiorr. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR P.O. BOX 76 HUMAIN REDLA'TIONS PERCOLATION TESTS (115) MADISON WI 53707 '1A Gy (H63.090)&Chapter 145.045) LOCATION-4 SECTION:� / /��/N/R/9i(or OWNSHI LOT NO.:BLK.NO.: Serer' IJI� Jj04 ^S Ies 0 COOUN/T�Y: OWNE�fltii�ER'S'nf>!#E: MAILING ADDRESS: 1 5k 5VOIr 2— USE DATES OBSERVATIONS MADE [)&esidence NO.BEDRMS.: COMMERCIA DESCRfPT10N: PROFI L DE CRIPTIONS: E AT N TESTS:lew ❑Replace C �j 7 / C 7' RATING:S=Site suitable for system U=Site unsuitable for system / L� r d rw?i AU L: MOUND: IN-GROUND•PRESSURE:SYSTEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM-(o tional)EIU Y. If Percolation Tests are NOT required DESIGN RITE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: c/ins X Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION ­—OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE A BRV.ON BACK.) B- /d,S� 95'3'0' /VO #>10,S B- B/s/ 7. 3' &A .- B- /Qr s /S,yl > /d�s ' 7 �js �. d ' �3t/.vw 5 y" f,V'6h Y B-Lt 9,7S 9y, 7` > 9. 75` ` B- s // 33` 9C, LS /1,33` rl ' r33� is ✓ /d,g3 ` ✓. B- PERCOLATION TESTS TEST DEPT WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER rAFTER WELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIODS PER INCH P_ I 3 6 & Z 3 P- L i I 1 1 3 4 G 3 P- 3 3 G 3 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 `d`7, V, _- , , r _ _ 4-� ' � W -� _ � , _ _ _ _.. � a P. P E( : t Pe�, �4V I W PC)Mir � i 9 jf i _- 40 - tt f t . ...,...-;.; .1_........-....... -.... --t -1 - i i _ d _.-� .-.._ �_ _ _ .�� __ _..._ _ ..w g _-. . . _.1_ I�T ca( . s la py 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 (pri P. TESTS WER C MPLETED ON: I��ael 2. ��. 7 ADDRESS: CERTIFI ATI N NUMBER: PHONE NUMBER(optional): 101 TeKYt- St. k s0"U- dl� cs 3 1-4 - 3/ CST SI N R DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. �DILHR-SBD-6395 (R.02/82) —OVER — dk ° P B. L. 6 7 P L OT A N F) C.- T O S S SECTION t 'N A M E NAME K . IIJ ' 0 C AT I 0 NIT I_ I C E N S�E 7 . P L 1- Nd .A_P -- -� ,,,, IT, C if.CAI ;r .. 2 6 W ; f 15 81= 104,0 EL �ecKoom N�. 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