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PUMP'CHAMBER I,
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size,
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan). HVANF. -
5W. '112
SOIL ABSORPTION SYSTEM Ito 0
I .,I
Bed: ✓ Tr QOd'`~ Be 1, ~3
Width: 18 Length: Number of Lines: 3 Area Built: 3(p
Fill depth to top of pipe:
ya~~
Number of feet from nearest property line: Front, O Side, O Rear, OPt.
Number of feet from well: 'nhIO
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job. BUL'n-u~
License Number :
3/84:mj
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT Q
OWNER M1 lie CL,~ 1 S e N S TOWNSHIP u J50 N SEC. Tc)1 N-R o~() W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT , LOT SIZE
AN VIEW
Distances and dimensions to meet requirements of IZHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
g.
3'
l ~ x5
yo' ~
SZi I o
0
o i I
a ► i I
i
j Be pmo rn N
Howie
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used StuI Plot
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: We Ks Liquid Capacity: 1000
Number of rings used: Tank manhole cover elevation: 10a. 3Q
Tank Inlet Elevation: ~a~7~P• Tank Outlet Elevation: ~Vo
Number of feet from nearest Road: Front ,~Side,O Rear, O 1 JS feet
, . From nearest property line Front,OSide,ORear,(Q~ feet
Number of feet from: well SS' 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 DIVISION
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS
BUREAU OF PLUMBING
MADISON WI 53707
N.T44, W ;S13,T29N-R20W CCONVENTIONAL ❑ALTERNATIVE (If assignad)D. Number:
FS-t.t; Plan Town of Hudson e'f. Holding Tank ❑ In-Ground Pressure ❑ Mound
Lo t• . Croix tation y`
NAME O MIT HRI 96- ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Wayne F. Moser & Murray Knech 213 Locust, Huds , WI 54016 7
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 95992
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
~q PROVIDED: PROVIDED:
' ~ IQ(,( loo,~v DES ❑NO ❑YES ®NO
BEDDING: VENT DIA.: VENT MAT L.: AHIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: ~VENTTOFRESH
4 LARM LINE AIR INLET
Cs- ❑YES ®IV0 ST_ 1
❑YES CIVO FEET FROM
JJ o►
DOSING CHAMBER:
MANUFACTURER. JBEDDING. JLIOUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing ji1111,TFI JDIAMETER 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. NDISTR. PIPE SPACING. COVER J INSIUE DIA.-. #PITS. LIQUID
BED/TRENCH TREIQHES ~I MATERIAL: TPT DEPTH:
DIMENSIONS 6t`
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. R OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER. ELLEEV.I NLET ELEpV i~END. PIPE!!t ROM LINE ~j AIR INLET:
~If `I- '4A~ -rl J? T= +
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.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS.
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: aDED SEEDED MULCHED.
CENTER- EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑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: P EANSCAL LIFT CORRESPONDS TO APPROVED
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: TNN ER OF PROPERTY WELL: BUILDING:
LINE:
FROM
j.~ ❑YES ❑NO YES ❑NO EST
r
I f
Sketch System on Retain in county file for audit.
Reverse Side.
ATURE: TITLE:
trator
Zoning Adminis
DILHR SBD 6710 (R. 01/82)
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT j
APPLICATION
to
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.. R gew,.permit rmay'lie needed ►
if there is a change in your building plans, system location, estiriiated wastewatdr flow (number of bed-
rooms, etc.),, depth of systerTL or type of system; !
4. 'Changes in ownership or plumber requires a Sanitary Permit Transfer/Flenewal• F/06 (SBD 6399)' fo-be
submitted to the county prior to ipstallation;
5. Private sewage systems must be'prop'erly maintained. The septic tank(s) should'be"pumped by a licensed Ff
pumper whenever necessary, usually every 2 to 3 years;
6. If you have g4estions concerning your private sewage system, contact yoLr local code administrator or the
State of Wisconsin,'Bure'au of'Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
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, 'ndicate 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;
Ill. 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 4n 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: Certifie~d,soil tgster's name, certification number, address, 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 „u
required by-the county; E),soil,test data on a 115 fornr. r
7 -
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 0~ over 2 years of steady negotiation and public deaate. The groundwater 'bill Groundwater
included the creation of surcharges (fees) for a number of regulated practices which Wiscori$in's
ran effect groundwater. The surcharge took effect on July 1984. All of the water that buried treasure
is used in your building is returned to the groundwater through your soil absorption t
system or the disposal site used by your holding tank pumper.. f
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,
s worth protecting.
5607-G398 (R.03t86)
L
SANITARY PERMIT APPLICATION COU T
TEYILHRI
In accord with ILHR 83.05, Wis. Adm. Code - vR~
STAT SANITARY ;99 PERM( #
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 rVJI NO
PRO ERTY OWNER PROPERTY LOCATION
NA mo MAKAIA NrW i,, % ~J W'/a, s 13 T , N, R Q Q E (or)
PRO QWNE 'S MAILING A DRES ¢ LOT rBER BLOCK NUMBER SUB 1VISION NAME
3 cus o s w
Y, TATE j~ ' ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE R LAN AR
I%k K
icz 11 Q W ISC• O' ❑ VILLAGE : S O S St rAk S LVAN 1 N .1( 1 TOWN OF- ~yl II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family o OR It Public (Specify): dN A
III. PURPOSE OF APPLICATION: (Check only one in #1. Check 2,3 or 4, if applicable)
i
1. a. NNew 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. E1 Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. E1 Pit Privy d. E1 Vault Privy e. E] Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 9Seepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(M~tes perinch): REQUIRED (Square Feet): PROP SED (Square Feet
3 1,5 3(10 1 TS Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concr to Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank
foo0
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
4 _j
PI.. fiber's Address (Street, ity, Sta ,Zip e): Nap of °rsigner: ,
G m , S _ K) LhA d
VIII. SOIL T ST INFORMATION
Certified Soil Tester (C T) Name
VA y~, 11 CST #
IV
CST's ADDRESS (Str et, City, S te, Zip dA Phone Number It
kso °s_ d 13~~0
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa nary Permit Fee Groundwater I-Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial X11 ~S9y~rchharrg^e Fee
Adverse Determination/" 6' oa d l
X. CO MENTS/RE SONS FOR DISAPPROVAL:
iaj C, &k L
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
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 Z-4 L/ Y) e
Location of Property AW Section , Tez,?f N-R c;,?0 W
Township SD O
Hailing Address C47/,3 46das r
Address of Site
Subdivision Name s pryt yn-e r"~G9~^y~ '4
Lot Number
Previous Owner of Property /C
Total Size of Parcel C: -
Date Parcel was Created e,
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? x Yes No
Volume i ~O^ and Page Number 4'7fZ)~ 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
1 (We) centti..6y that att atatement6 on this 6otm ate true to the but o6 my (out)
knowledge; that I (we) am (ahe) the ownet(a) o6 the ptopetty deacti.bed in th,ia
in6otmation 6onm, by viAtue o6 a waAAanty deed tecotded in the 066ice o6 the
County Registet o6 Veed6 ass Vocument No. ; and that T (We) pteaent ly
own the ptopos ed site Got the .sewage d igs po.6 d em (ot T (we) have obtained an
ea.aement, to nun with the above ducA bed ptopetty, Got the conattuction o6 aaid
ayatem, and the came has been duty tecotded in the 066ice o6 the County Reg.cateA o6
Veeds, as Vo ent No.
SI A TUA/ 01P
cOWNER SIGNATURE CO-OWNER (IF APPLICABLE)
DATE SIGNED DAT SIGNED
DOCUMENT NO. WARRANTY DIED ! THIS SPACE RESERVED FOR RECORDING DATA
STATE OF WISCONSIN-FORM 10
42 324 780PVr.
REGISTERS OFFICE
SOMMERS .
' THIS INDENTURE, Made by ST. CROIX Co,, WIS. i
ROed. for llReccrd this 1 s t
a Corporation duly organized and existing under and by virtue of the laws of
QkQ of June A.D. 19$7
the State of Wisconsin, grantor, of........ t.._Croix _
I! ...._...WAYNE F F. MOSER - - ' 10:05 ,
County, Wisconsin hereby conveys and warrants to..._.._.._
and MURRAY NECHT, as tenants in common and not
- - - -
as joint tenants, rantees._
g -w . - 6~Mier of Doode
St. Croix County, Wisconsin, for the
Thirty-seven Thousand and no/1D0-----------
s~~13~1, OOb . 00) •Dollars---------------------------
St. Croix i RETURN TO
the following tract of land in - - ,
State of Wisconsin:
I
Lot 5 of Sommers Landing Addition to the Village of North Hudson,
St. Croix County, Wisconsin.
it
TOGETHER WITH and SUBJECT TO easements, reservations, restrictions
and rights-of-way of record, if any.
I~
i~
'I
I
~I
I'
I
(IF NECESSART, CONTINUE DESCRIPTION ON RETERSP, SIDE)
In Witness.Whereof, the saidlgrPreoident,candcountersgnedtby _ ~e_Sandra. •_J ~.•_Penfeld_t•--Pe~f_i~eld ,II
Hudson
its Secretary, at Wisconsin, and its corporate seal to be hereunto affixed this
29th Mav 19J17
day of ----•---------.......---i A. D.,
SIGNED AND SEALED IN PRESENCE OF SOMMERS LANDING, I14C
i Corporate Name
II
Ptasid nt`
Al le Penf ie_lq~ , t-_fi( Ii
_ t
COUNTERSIG 0-
_L-i
ark
Sandra J. Pen i 1q
STATE OF WISCONSIN
St Croix SS.
County.
I~ Personally came before me, this da of A. D.,
Presidnt,and_..___Sandra__JayPenfield_____._-_...__--_, Sece$tary
II of the above named Corporation, to me known to be the persons who executed the foregoing instrument` and to me I',I
known to be such President and Secretary of said Corporation, and acknowledged that they execrated ffie,Jordgaing
instrument as such officers as the deed of said Corporation, by its authority. J F
o.. ASN I ►vSKI '
nr)
~I THIS INSTRUMENT WAS GRAFTED BY
Robert W. Mudge r . tj Croix G
---------------G 1. `
.x
` NDEEN Notary Public S 1~ 's
I GILBERT, MUDGE, PORTER &Ir
aa, commission (expires) (is) -
-HYi -T-VT--540-1 - 6-
(Section 59.51 (1) of the Wisconsin Statutes provides that all instruments to be recorded shall have plainly printed or typewritten thereon
the names of the grantors, grantees, witnesses and notary. Section 59.513 similarly requires that the name of the person who, or govern.
mental agency which, drafted such instrument, shall he printed, typewritten, stamped or written thereon in a legible mariner.)
WARR,VNTY DEED - n3 Corporation STATE OF WISCONSIN Wisconsin Legal Blank Co. Inc.
I-OTiAS N,, 10 MilwAnkee, Will.
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STC - 10.5
SEPTIC TANK MAINT'ENANCE ACRIiEMt NT p
St. Croix County u
• o
OWNER/BUYER ,Q (Z;f Arl &Y r-q- CCn .14 T rn
ROUTE/BOX NUMBER -09/3 Fire Number
CITY/STATE ZIP
PROPERTY LOCATION: 1%014, SectiunT';0, ?6 w.
Town of Al"'95a0 St. Croix County,
Subdivision :~-bm-W.rS Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Pruper maintenance cun-
sists of pumping out the septic tank evury three years or sooner,
if needed, by a licensed septic tank LmLer. What " you put into
the system can affect the function of the supLic tank as a ereae-
meit t'stage in the waste disposal system.
St. Croix County residents mum be eligible to receive a grant for
a maximum of 60% of the cost of replace:me:nt,of.A fsili.ng system,
which was in operation prior to July 1,.1978. St Cru,ix County
accepted this program in August :o.f..198U, whit' the requirement that
owners of all new systems agree to;keeli thutr systems properly
maintained.
'rite property owner agrees to submit to St. Croix County Zoit in.g a
certification form, ssignud by the owner and by a muster plumber,
journeyman plumber, restricted plumber or a iicensed 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 drys prior to
three year expiration. H
o
I/WE, the undersigned, have read the above requirements and agree N
to maintain the-private sewage disposal system in accordance: with
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 Offkee within 30 days
of the three year expiration date.
SICNE
.
• DATE '
St. C11oix County Zoning Office
P.-O. I' o X 98
Hammoi d, WI 54015 1
715-7S 6-223 or 715-425-8363
Sign, date and return to above address.
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 r . .
To be a complete and accurate soil test, your r 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 - cement system;
5, Complete the f lity 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 sure 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, i.. r;propriate;
10 If .1 wmation (such as flood plain, elevation) dc--, ° - apply, place N.A. in the appropriate box;
11. Si; .l n and place your current address and y( it ition number;
12. Make I ble copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
i
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
col.; Cobble (3 - 10") SS - Sandstone
gr - Gravel (under 3") LS Limestone
- Sand HGW - Nigh Groundwater
Coarse Sand Perc - Percolation Rate
- Medium Sand W - Well
Fine Sand Bidg - Building
Is Loamy Sand > - Greater Than
sl Sandy Loam < Less Than
'I Loam Bn - Brown
sil Silt Loam BI Black
si - Silt Gy - Gray
- Clay Loam Y Yellow
- Sandy Clay Loam R - Red
s Silty Clay Loam mot - Mottles
Sandy Clay w1 with
sic Silty Clay fff few, line, faint
11 c Clay cc- cornmon, coarse
pt Peat rnm - Many, medium
m - Muck d - distinct
p - prominent
HWL - High wat '~vel,
Six general soil textures surfac(
for liquid waste disposal BM - Benc
VRP Verti once Point
TC INR:
sc" t report is the first step in secur:+tart' permit. Thr r aunty D -r nt may reuUest
this soil -t in the field p+ . rmit issuanF, is f r the private
t ri any l ;-lication mra. bn~itted to 0 au yin order to
°lit. - Cr mars' nd posted pa >r - - of any et-, i,
i
L
DE UST. 'R ' OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN REI„ATIONS , 53707
. (H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/ TY: OT NO.:BLK. NO.: SUBDIVISION NAME:
j1 f o NW JO/ / 3 /T21N/IQ0V(or)0 14 > 5do, 151 1 $4 Cr 0j') . ~JS~. ka sl
Ct,UiNTY: O N IR'S BUYER' NAME: G e 5 MAILINGrADDR ESS:O US f~~ ~SOn W 5'V-016
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL SCRIP TION: PROFI.VE D IPTIONS: =7P
TS: Residence o~ New ❑ Replace RATING: S= Site suitable for system U= Site unsuitable for system
C NVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLWS DING T NK: RECOMMENDED SYSTEM: (optional)
au au ~ds au 5ds ou EIS ®u EIS NO 69 ie.. lAonl
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the J
under s.H63.09(5)(b), indicate: / 3 lFloodplain, indicate Floodplain elevation: N
fi PROFILE DESCRIPTIONS
BORING TOTA DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED ES IGFEST TOO BEDROCK IF OBSER,V+ED (SEE ABBRV. ON BACK.)
B- 7/7 1 JO L, 7 Z .1
r w Go~~
04t >7/7" e 1 61" 5/ SS- 5-11/S 411
B- 7 0 75
> 7, 0 S S~ r D is r w co,~
B- 3 7.q2` lit. ~s 7, 9 Z . S~ / I, o ~sl , ~y ~/s w 6
B_ q 73V' 10 2. 7 ~ ~ 3 y ~ , '93 Y ,f s sv4aA
B- 5 7.0 /o/13 > 7 v S ~34"AW4'r'&WIC4
B-
PERCOLATION TESTS
TEST DEPT WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFT RSWELLING INTERVAL-MIN. P I D2 PERINCH
PERI 1 P R
P- i , nA. a y ~~y 3 , 33
P-1 t ~Voru~ I f E l A •
P o' IC 7 r -7/f A 513
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
3 t0 3 F E
I i 3 f % i
s
I ~ ~ ; t ! I 1
3
17 i
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- 41
t i .
0
821 /y{J. / of Fo 11~.. a
F
, 31
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Slot 41 d + W
i,
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (p int): TESTS ERE ,,COMPLETED ON:
ap, tJe- sz P 7
ADDRESS: CE TIFI ATION NUMBER: PHONE NUMBER (optional):
CST SIGNA
dom. a..
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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'fy t FRESH AIR INLETS AND OBSERVA TT(~N Pi
y ~ CROSS SECTION
Approved Vent Cap
103-
Minimum 12" Above
e Final Grad. +Nh0 q
. ? V.
y)
MAY
4" Casa Iron
Above Pipe Vent Pipe
To Final Grade
Marsh Hay Or Synthetic Covering 1
Min. 2" Agg.r. eg'I,a I.0
Over Pipe ~V
Distributi~~ 11~ J Tee
Pipe
Aggregate Perforated Pipe Below
ISIS Beneath Pipe 4 Coupling Terminating At
~or~d NI~J Bottom of System