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SOIL ABSORPTION SYSTEM 2 ~~~~{FS J Bed: Trench: / Width• 5 Length: 56 Number of Lines: ~E~ Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 Pt.~ Number of feet from well: 0a" 3. 00 aUek 3od Number of feet from building: (Include distance„s.on plot plan). r SEEPAGE PIT Si Number of pits: Diameter: Liquid pth: Bottom of seepage pit elev on: Area Built: Has either a drop bo or distribution bo been used on any of the above soil absorbtion sytems? (Chec one). HOLDING TANK Manufacturer: Capacity: Number of rings uspd/ levation of bottom of tank: Elevation of et: Number of eet from nearest property 1 e: Front, O Side, O Rear, OFt. Number of feet from wel Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: ~j v Inspector: ~ L a 7 Plumber on job: Dated: License Number: HOMESITE SEPTIC PLUMON CO. RT. 3 O'NEIL RD.: HUDSON, MS. 54016 ROBERT ULBRICHT vVIS. !'OVER I•LUMBER LIC. NO. 3307 M.RR.1 3/84 •mj ,AINN "WALLER & DESIGNER LIC. NO. 0060 3 0' 3 f~7 e-~e ' Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T 2e N-R /r W PI-2- (3o x ADDRESS ST. CROIX COUNTY, WISCONSIN, SUBDIVISION -17-77 V PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 9CQ~it°r7~ 7~i,✓K SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I 30 47. S/f IrF6ES war /-v e f to • Y" 0~ s i,vrP~cTro,.. yi~oE ~D ~ f~Rq Eva ovtG~l '8+fl, = To - Pr. 3 ~M q~ I'F (06, DD . o ZOO, 5 o y3 ~ ~ LI' 50 f (oSr~p of P,IVEu'-'~ Se ,e . CE VTt gliffE . A9010 es 0% EAST TiPENCff !FEEDS f~it'fT, 39Z"d T,W,lc So v Porgy ~ , ism ~ Ye r•~to sT pPooF ' ~ I I S7' O I X, I I ~av~Q~D v'~ 7 y~'FR ~/%G -r BEN e s~ uvPFnwe.11-1 27 ~1 ~~sT. o 5 5TEAA fleVATI'00 `g ale, ?ecAx C e S 'Y3. 3 D 9y 13 INDICATE NORTH ARROW C i 272 hT- ue,0r S -roe OF 0-Y, c-S D/ -Fo of so-K- 27)--f( 4r ~Ve-,fP&A 9/13 t .O/ To OF 44VAWv.ti 5, - ED u T DOOR I~ BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: ~D Proposed slope at site: A/oT e"ocv.✓ - T~ ~K ~t+E ~r~oa s 7, p'Dify X S S' vE>P (:57X S SEPTIC TANK • Manufacturer: L i uid Capacity: q Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: ~g Tank Outlet Elevation: 9 ~11 Number of feet from nearest Road: Front,(),-') Side,O Rear, O (7W4 300 feet "fr From nearest property line Front, 0Side ,ORear, 0 Q ~0 feet Number of feet from: well 7& I , building: / 3 , (Include this information of the above plot plan)( 2 reference dimensions to septic tank) OVV DVXYV,DCV CTnr• DEPARTMENT OF INDUSTRY, j INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 MADISON, WI 53707 BUREAU OF PLUMBING SW'-4, 14E%, S9,T28N-R18W IXCONVENTIONAL ❑ALTERNATIVE State Plan 1. D. Number: f Town° of Kinnickinnic ❑ Holding Tank El In-Ground Pressure ❑ Mound (If assigned) Valley View Road NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE John B. Hill Rt. 1 Valley View Road, Roberts WI 54023 _j 97 //.1130 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber: MP/MPRSW No.. Coumy: Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 95997 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LI UID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER r PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO BEDDING: [VENT.: EN MAT ATER NUMBER OF ROAD: PROPERTY WELL BUILDING: (VENT TO FRESH M FEET FROM LINE: AIR INLET: ❑YES ❑NO ❑YES NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL JPUMP/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. VENT TO FRESH (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 11 rN IDIAM ErER 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: BED/TRENCH WIDTH LENGTH IN EDF DISTR PIPE SPACING COVER PIT NSIOE DIA #PITS LIQUID TORNCfSt S. / M RIAL: DEPTH: DIMENSIONS L/Ji GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES l/ ABOVE COVER : ELEG ILET. ELEV. E, PIPE FEET FROM LIN ^ AI LET. 77 23 /T NEAREST ~J lr^~V 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- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOI L. SODDED. SEEDED- IMULCHED.• 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.: CIA.: ELEV.. PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST e I in county file for audit. SIGNATURE: 7 TITLE: vIR.o1/821 Zoning Administrator INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. wisconein APPLICATION FOR SANITARY PERMIT (PLB 67) COUNTY ~DILHR s~• OEPRRTmEr1TOF UNIFORM SANITARY PERMIT # MMMPN~= InOUSTR4,LRBOR&HUMRn RELRTIOr15 9s9,9,> -Attach complete plans in accord with s. H 63.05, Wis. Adrn. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNE MAILING ADDRESS p~ TO 4 6 - H III TT- I U1A k 01,E W W- 1`~ A E P TS to IS PROPERTY LOCATION q le 4 t"'- - SW 1/4 ~E/4, S T ~N, R /S E (or W ' To-r-A : 1~ INN L(~r'.v v! G~ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, 1 nKF OR I nNDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ~13 ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK, ~ 2 ~i;vES E~GG~ •j x S.S. 0, ❑ Seepage Bed Z Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued - D An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. TO Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity o I Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: 41O 7- . vzq., Z(i✓ f i~ _4X pos r L:> o a m F_ W Co ti.j ee V O,J /NS,p~E~T~D d IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure e-O F etgl ~,fvn Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): S Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (P Signature: MPRSW No.: Phone Number: RT. 3 O'NEIL RD.: HUDSON, WIS. 540 P64- 3 3 O (j/S- 13~~r ~~~s Plumber's Ad'4V:t1yKI1R PLUMBER LIC. NO. 3307 MARS Name of Designer: MINN. INSTALLER & DESIGNER LIC. 140. DOW Z>/L~JQ/ T i IRCOUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: - ,Q ❑ Disapproved Ce>7~ ~Lc?'OG' CC Cr ~ ~ Approved ❑ Owner Given Initial Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) 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 - V N-R~ Location of Property s~ i% N E Section , T Z,Q /~/.!Jill G A/A) .C- Township ~Q Mailing Address In X,166X 7_5 Address of Site Subdivision Name Lot Number Previous Owner of Property A) C'ES ~A7 .5-S07T Total Size of parcel 7 Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume and Page Number 34oO 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPFRTV OWNER CERTIFICATION I (We) cetti.gy that a2,t Atatements on this gotm ate tAue to the beat og my (out) know.tedge; that I (we) am (ane) the ownet(a) og the ptope&ty dachibed in this ingotmati,on gotm, by vi4tue og a ww anty de tided in the Ogg~,ce og the County RegisteA og Deeds o Document No. Z to ; and that I (We) ptu entty own the ptoposed site got the .sewage dispozat em (ot I (we) have obtained an easement, to tun with the above ducnibed ptopenty, got the constAucti.on og .said ,system, and the same has been duty tecotded in the Oggice og the County Reg-ustet og Deeds, as Document No. SI TURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED y'{r. 7114 pp,y1R' d M~4'~)'_41p, J EF,~ YA• t"c 1 At 71+4Fx ,C r,~~4{I s r~,1 a~°fr z r1 E tf ~ ~a T Y ~ ~ 3~ ""ri"'R' ~ ~ ~'~g,1,~ v~ra'l } t~ P }+f , ft '7 yl.',•'%~+s , r rf, s~~ r~w,,t ,{v1rw a+ ,,/qy~ ~t 0. r, ),~i> { ay h;~tptsgK~ ,ter r a > ' f trS'i y ~„»'4~t~,~'~ ...t. ..J'l ui• `d' r~'i r; 4 t, '.,.r. ..u k,..Er", ."s.. E. J gyp. STATE, I3AR OF WISCONSIN- F OPM 1 DOCUMENT NO, WARRANTY D rD THIS a ~y Jp S SPACE RESdRVED I Cyi RCCChDING DATA ~:1 h ~ l3 ~~1 ~ r rG; t t Tim,; UF.h:U, m:.dr h,:twetn Franc 1 ,a Fa^`:et t a1 Francis Y° F.: n,tt.-and- 1_.. n E'"Il et- C'1_as -J_OJntFtenants,. ry 'I' Rt.C'_i )t< s(`ccgl, [,il.'. IQ h. - to 71 ri and __John _B H J 11 and Onnolee F. Hill, _husband arld S -Wife ARr- Witnei4 aeth, That the said Grantor for a valuable consideration TWentyr six I VtCgl.,tef of D .rfv thousand dollars - Croix conveys to Grantee the following described real c.,t cite in County, ~ RETURN TO State of Wisconsin. The South 11,00 fret of the !,le-1, 600 feet of the SW4 N 414 of Section 9, 1'28N-Rik Tux Key - - This is ._-homestead property. t, { FAX STA-r E' It rS E Cr : Tt [:CSCRI3LL~ t1,4i HIS TRA t _ EIR B SENT TO' % Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise oppertaining; AndFrancis_ E. _ i' asset•l,_ and _Marilyn_P...__Fassett_---- warrants that the title is tr,ood, indefeasible in fee simple and free and clear of encumbrancer; except _utility and_ road-- easements-recorded or_ otherwise___-___ and will warrant and defend the same. Executed at R0~4rtS.,____ _.J,. 2CQ.l1iiT1_ _ - . this r SIGNED AND S[?ACED IN PRESENCE OE (SEAL) Frarlci2 E. Fassett aka 1 rancis Fassett (SEAL) lvlariYyn Fassett aka Marilyn Fassett (SEAL) 4 (SEAL) T • . rY, nc u ~ . aJ~, ssetrt and Marilyn I F:D- o- Lt 1 p ' auth n>.1L~ k hES. h a>r of ])n tlct) iF 1'1 r (Z 0 >77. a E :Ldrr1 fi , 13ader. t ON `.7 ] rl :;1,x_6 nih".,'°.X r A YG`fiY.'}1}fj'l OtlEer Party ' ~ Ac Iiosez°•rl under Sec-. 706.06 vsc..l~otary-_Public ;iy t.r,Inr: ss.ion expires 5-29-77 j STX T, 61 VVISC0N';IN ~ f _ County, "sj' Personally carne~l;r•trnr m1-, thir: _ _ . - - - d>+y c,f 19--- r the ahove nanu'd to mt Icnorm to he rho ptvson v,-hoccents d thu 1x~EC s trE[; in .ts anent rnod rcl uo v~cdt?c:l the c: i a. 4:. This instrument w.,~ drAtc•,i Sy s. a .Lp!.o.( County, V.'iti The usu of o.ttae ,.;s in optional, tril d n:r:i' SinE! ('°xpir, t,) 'i 1 Ntmea of perrony >Et' zttf in any rapt.c a h:;u' t t,'pr :t or printer r:I~ t6es F er Rcra:,rrlt,m ~n rvs 1' l t ARRAPTY [)E f.D -SC.4f i•: iiAR R( N,CC ciE .'!c. t NO. l - 1971 ~ ft9• t,_• ? 1 xY a..e......,.., 1i I! ' ,l, w s`S'r <~.r•et C< dams °~q6 r r~ u t c..;';, 'H 'JY , t v ^6~." txtc st rNYa }K'~'>~-' , Ytr' 1 r 5~ S, t7 dqt w f~ia, `~`f 4ry4.~.r } ~ „!S,>•~ 'K-~ ~~M ~ y y~ ~~i~~kl~i ~+,~Jt~r 'rTf ~r `i~? ~ tip •4 ~r '1 EE ~ ~ ~ r ;r ~ C ~s~ •k i . - r z H' a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a jq- OWNER/-BQ.YE$ 13I I ROUTE/BOX NUMBER We Number CITY/STATE 'i~5 3Er- 7- S 400 ZIP sS T 4 23 PROPERTY LOCATION: 51d 1, Section T 2P N, R ? W, Town of l` 'y~.CK St. Croix County, Subdivision Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank.is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. Ho E 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- ro 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. QD SIGNED DATE 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. 1 6f RTM, N7 OF -REPORT OIL SOIL BORINGS AND SAFETY-& BUILDINGS-- AND 1L~DIVISION Will ANW. PERCOLATION TESTS (115) P.O. BOX 7969 N RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) SECTION: MeATIO J-- TOWNSHIPIMUNICIPALITY: OT N0 BLK. NO.: SUBDIVISION NAME- 1/4 /T)FN/R19E(o COUNTY: 'MR-MMYER'S NAME: MAILING ADDRESS: use DATES OBSERVATIONS MADE NO. B : COMMERCIAL DESCRIPTION: F DESCRIPTION S: PERCOLATION STS: esidence z ❑ New Replace PR 9-1 - JP 3 RATIN TS- Site suitable for system U- Site unsuitable for system ` O " - r •S,V13 `r7xd,4 jA 5 ONV L: MOUND: IN GROl1N PR EISUR. : S ST -IN-FILL OL TANK: RECOMMENDED SYSTEM: (optional) S. DU S CJU ®S []U CIS ®U 0 S ©U ~o~vd~~u 7kof L. 0 'X ' f HA//O ccJ _ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s,1-163.09(5)(b), indicate: IPA/ 40000,m ( Floodplain, indicate Floodplain elevation: is 44R , PROFILE DESCRIPTIONS /.U BORING TOTAL ELEVATION DEPTH T R UNDWATER-IN . CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER E~PPrH F73 OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) '(1 ,.SiL / 4-67' RG7E'eN~47/,J - IB- / o , A - > 7v , (0 7 ' , i AJ- S/L 6p 7 13 i4R o Ii o.vDS k L S B.' 7 9l0 3 7 ,v s . Ste- I r ` & /5 AWII l kJ Q I Y133 S!L ? /t*!Y• oL & S w o kJ PERCOLATION TESTS oG CdLGr gt; L Jr TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI O PERIOD PER INCH P. / P- P_ t 3 III' P- 02. P- j ll" i PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate state or distances. Describe what are the hori- zonthl and vertical elevation referen-ft, points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 13 e TTa~ aF 13~D el:W.# U'rf` / lev SlyE'.,)_ SYSTEM ELEVATION x~►c r~ Y (0.7n r7. 64-4-__ let rl I - i's gee Ire I I F~ r..__. I 1 . I I ( i I I I I j I ~ ' ~ ! I j ~ i i I I t I ; 1 ft _ .r i 1 I 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 data recorded and the location of the tests are correct to the best of my knowledge and belief. i NAME print : TESTS WERE COMPLETED ON: MOMESITE TESTING CO. ~3 ADDRESS: i r V . ROAD CERTIFICATION NUMBER: PHONE NUMB ER(opt ionat►: S5 =G ~ 3 0 1 HUDSON, WI S- 540 16 CST SIGNATUR : i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. e - 0ILHR-S80-6395 (R. 02/82) OVER DEFARTME~,aT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, VISION LABEIR ANIi PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS 1 MADISON, WI 53707 i (H63.09(1) & Chapter 145.045) gig LOCATI N: SECTION: TOWNSHIP/MUNICIPALITY: OT NO.: BLK, NO.: SUBDIVISION NAME: j S w i/ N/R ~E (or "'ej;volc a COUNTY:. OWNER'S BUR'S 3, NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE Residence ONew Replace N+ d' F-- 7j _ RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSUR : SYS EM-IN-FILL HOLDIING TANK: RECOMMENDED SYSTEM: (optional) S ❑U CAS ❑U ©S DU OS DU [IS 0u s'e_Q i If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s,H63.09(5)(b), indicate: I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. IGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 6A) - 41. ,P. -~3v s , 3. le- B- da 7 `J S g, G1, S d - S 'e 010 _/14) . 4 J-, 20 C. e- 'OF ?*c -h'4- s' -2,& 7'13,4- 4~4 s-CL _ Fr B- r~vE' sEEio~f g r S Fr . B- . I B- i B- I PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER INCH P- P- j P-Ca OZ 4A P_ [PP_ - 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. 1 SYSTEM ELEVATION / T I I , ! 1 I ' tt , i xi ! ) : ~f y I I ~ i ~ i ; I I I f I j I , 'c4v Er: II I I : . o u~v I-l~l . I I 1, 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, TESTS WERE COMPLETED ON: NAME pri"` : HOMESITE TESTING CO. AT. 3y O'NE;L ROAD ,.ADDRESS: CERTIFICATION NUMBER: PHO. E NUM ER(optional): H6DSON, WIS. 54016 S-S-_ OZ y~L 6 - r/ CST SIGNATU E: • - i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. r fI DILHR-SBO-6395 (R. 02182) - OVER - i j 'REPORT ON SOIL BORIN&S ; PERCOLATION TESTS iIS Rrv~~i~ y Pbor PLAN PROTECT r. D. R DA rE -~3 HOMESITE TESTING CO. AT.3, O'NEIL ROAD .BOB ULBR1 iiUDSON, WIS....- U016 CST ' SS- d2 y~Z PROPOSED HOUSE mosr LIE Z.!~ Fr. at me-cE FROM q1.1. TEST "'C,45. p POSE 0 W L a M vsr LIE ,Sp Fr. oR MORE FiPo ti Act TEST iy~PEilS, • = t3,gtd'fj~,E Pirf O = EXifT/~J G- !.DELL X ` Aev6 1AC,#r14vf AUP A09EQE0 At 544WW I f lo,~iz . B M1 VFR1i hl- , DCJ-,# W4i- polar _r014 of- d" "'o LE GE N p PT. /EV~row of 1/&f. #PEF. ~T I°l /0 0 0 EIC~~`p°~ I,oG' o`V ~rle^~E 4 F+RE _ FED G!r R1~~ RQxFt a , LS R~,w° y00 o t,¢ m 48 i Pv S/oPES i 13 O (pOODf it 13 v" s-/&d -Ti"o,c) No S o!~ S J0,4 ~{~Qow D~PAiNFiEZD 40 6W ty 1 ST 13 aeoiS w ~Qe / M~ v~~r ,per f pr- ?off Of RE,P, wo av co,P,v • `E,vcE-- ~osT ~'/emu, _ /DO. d O S i ed ` o D ept-R 0WASCR'; PuNPt~R ¢ 5 IS00 Sop- PRe•cAsr YE CoD~koP Se prrc TANK To Re 7,tscO t If- CODE L co N PLI4aT i N ~ yoop O~DD~2• 111 ~ ~ ~ ' 8Z r ~ ~ 1~~ 3o3y v 1 ~ ~ GAS 1A) . 3.c.~~ ~ 3 X3.03 ~ v Fresh Air Inlets And Observation Pipe M h 71PiCAL fob 4Tk- -t"i2ENct4r:5 w O Approved Vent Cap Minimum 12" Above Final Grade Fioi's fi€~ J P^0 r- /u 4" Cost iron 30 " Above Pipe Vent Pipe -fo Final Grade Marsh Hay Or Synthetic Covering Min. 2" Aggregate j Over Pipe I Distribution F70-0 0 0 Tee Pipe Aggregate P o Perforated Pipe Belaw Beneath Pipe ~~~/h1 J~IJ o Coupling Terminating At 93.3 rBottom Of System ` • v~ar REle Pr= 7010 Of RE,P) woao reevE~P I ~s ` a D PER QWaeRPUMPER 45 ~ Pa c~ I S oo Sop. ppe -cAsr t~ Coo~RoP $c-pr c- T-1Nlc 8 ~ Q y To QE uscP IF coDX 16 cc K PW'+NJT 1 N V ~ yooD oeoo~2 Bz I- , ;.7;L# ~r- 3o3y I cro y I I ~/p GAvp /0 v Fresh Air Inlets And Observation Pipe h -TJPXAL -fO12 •QOT~ "1'12E~1~C~E~S 0 Qom- Approved Vent Cap Minimum 12" Above Final Grade , ~i ~'s tt€ M /'iMUµ 4" Cast Iron 3o Above Pipe To Final Grade Vent Pips Marsh Hay Or Synthetic Covering i min. 2" A ; ggregote Over Pipe Distribution Tee ' -t 0 0 0 0 0 Pipe _rk, 71 P,(n " Aggregate o Perforated Pips Below / Beneath Pipe T o Coupling Terminating At 9.'> 3 Bottom Of System • ncnO' ncnp 3'0 n d c f 3 ~ A T 10 tz - 2 d o o = oS o w o CD co Z co zl- m 4 N A y ~j p 3 m D m CD \ C 7 N N v J C 0. 0 7 O j j 7 Co K) A N = m m l O O a 3 7 W CL n W Q i co 0 0 c~'D 1+. c A Q o 0 V N 3 N N Cc-,' 3 C4 N N~. O ~1 1 C d ~i A CD O cn <D aCD v>ZD eo ate' A N a K D (a O V+ Q CA CD CD W CD CD c a CL CD F; CL Ow ~N.l 06 Z coal 0 co 0 r- ca co co a l O OD o! y COT c m m 3 T o o ~y~ O z co CO) vii! D °0 _ CO) ci(A ~6 13 00 0 M N N O t0/r f~~D N A v W lei .Z1 = A A lV CD w =r 3 N) 0) CD 0 O. CL A Z rr Z r D CD o z m 0 0 O a O Er CD CD y A A y !~1 ;0 'a 1 .0 (O A (o N A c A fND W CL W a CL 3 7 a 3 CD m z OZ A z 0 43 q C N X w a a p ~i cn -1 co 00 A N eWD CDC m a a z oo °o z y w A ~p ? w w I (=p' y e a c m ? a 3 CD CD CL go Ll cD O o=i c c as c z a z a 0 0 o N tAii N N f<D N f', A N y O CD < O 3 j a Nt- a o y3 b !A N O• I I O tp n N a N I I o H = A N N DO o 0 o Q r N ~ o b °o a I °o a ~ DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & ,HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 796° BUREAU OF PLUMBING MADISON, WI 53707 7CONVENTIONAL El ALTERNATIVE State Plan l.D.Number: ( El assigned) D Holding Tank D In-Ground Pressure D Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: John B. Hill Roberts, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.: SWI-4 NE14, Section 9, T28N-R18W, Town of Kinnickinnic Name of Plumber: MP/MPRSW No.. County. Sanitary Permit Number: Mike Hawkins 5926 St. Croix 43714 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO BEDDING: VENT DIA.: VENT MATL.. HIGH WATER NUMBER OF ROAD: POPERTY WELL BUILDING: VENT TO FRESH ALARM FEET FROM ILRIN E : AIR INLET DYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY IV, ELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE ILI'11,TH 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: 'LIQU BED/TRENCH WIDTH LENGTH TRENCHES ]DISTR PIPE SPACING MATERIAL: PIT JINSIDE DIA #PITS D PTID: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL. BUILDING: V NT TO FRESH BELOW PI PES. ABOVE COVER. ELEV. INLET ELEV. END. PIPES. FEET FROM LINE: AIR INLET: NEAREST------P-1 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. DYES ONO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. DYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. ISCIDDED. JSEEDED-. MULCHED: CENTER. EDGES. DYES ONO DYES ONO DYES ONO 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: ELEVATION AND ELEV.. ELEV.. CIA.. ELEV.: PIPES. DIA.: DISTRIBUTION ERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: V PLANS DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. ]TITLE. DILHR SBD 6710 (R. 01/82) 777 L/ PLB 6 7 State and County State Permit Permit Application County Per i # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED r Date Approval Received from State if Required State Plan I.D. # A. OWNER OF. PROPERTY r Mailing Address: ~_j tgL_ta, v ( 0 ~ - \4/ (2-e B. LOCATION: l+JY4 Y4, Section T N, R 1 E (or) W Lot# City JF (_3 Subdivision Name, nearest road, lake or landmark Blk# Village Townshi ,.Qra l lsao& C. TYPE OF OCC PANCY: Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms 7a No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete-_ Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTE : Percolation Rate "V'2-2 I Total Absorb-Area- sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile deptlt p)No. of Trenches Seepage Bed: LengthWidth `-Depth Tile depth (top GG~ No. of Lines 7, Seepage Pit: Inside d'am~ter Liquid Depth No. of Seepage Pits Percent slope of land- RX Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information 1 have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the erti ied Soil Tester, NAME C.S.T. -k3Z4-61 and other information obtained from c 1J i (owner/kmi"). 14 Plumber's Signat u44 Q` Phone 4456,37 7 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. ►f well has not been drilled please indicate. E t t o a o ~A_ . o ~o 01 W a E 3 QC3 c 3 Do Not Write in Space Below FOR COUNTY AND ST TE DEPARTMENT USE ONLY Date of Application Fees Paid: States Ze County Date Permit Issued/Rejected (date) Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, W1 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 Form - S T C 100 Owner of Property_, 47-J Location of Property $'V) 461 F- '-4, Secti01'--~'T N It W Township KA)PICKIMIJIC Mailing Address f(~7- v, 60x 7 4 sp e~5 W SzidL-S Subdivision Name I Lot Number Previous Owner of Property Total Size of Parcel Date Parcel Was Created Are all corners identifiable? ✓ Yes No Include with this application one of the following: .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 3.2.3 .l 4 ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County egister of Deeds, as Document No. SIGNATU OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 3 /U DATE SIGNED DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN-FORM I WARRANTY DEED i~.;. 3 2 3 6 9 4 THIS SPACE RESERVED FOR RECORDING DATA THIS DEED, made between Francis Fassett aka Francis E. REGISTERS OFFICE Fassett and Marilyn Fassett aka Marilyn P. assett. ST. CROIX CO.. WIS. husband and wife as joint tenants. Recd for Record this-1010- _ Grantor day of_.AMU_PL+-.A.D.19_74 and John B. Hill and Onnolee F. Hill, husband and tI 1wr i f e , Q~R, M. Grantee, W i t n e s s e t h, That the said Grantor for a valuable consideration Twenty six Regkter of Oead2 thousand dollars conveys to Grantee the following described real estate in St. Croix County, RETURN TO 5T. F kU !k State of Wisconsin: $81 wl! di.a i i A ST. PAUL, N. " The South 300 feet of the West 600 feet of the ST. 6121224 Ivl1 SW4 NE4 of Section 9, T28N-R18W. Tax Key M This is homestead property. rAX STA7 a ENTS FO N THE _ q! ,''RO°ERTY THIS i. ` I~ N rl~uLD TRANSFER I I I $16100 - FEE ►1~A 5 0~3, Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; And Francis F. Fass_e_tt and Marilyn P. FaSSett warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except _llti] ity and road easem nts recorded or other-w-iss and will warrant and defend the same. Executed at Roberts. Wisconsin this- day of August 19-7-k . SIGNED AND SEALED IN PRESENCE OF (SEAL) Francis E. Fassett aka Francis Fassett (SEAL) ; t Mari yn Pr Fassett aka Marilyn Fassett 1 (SEAL) I - L - - (SEAL) i Signatures of Francis E. Fassett and Marilyn F. Fassett, f authest.ete4this. ~•2 th day of _ August 19 • w° Q; ' p ~~'~~C►~-c-v .mac A Eldon A. Bader Title: DQ$f11G*X=#(ZKXKZ=ODD XKOther Party Authorized under Sec. 706.06 viz. Nota= Fub11C ~ My commission expires 5-29-77 N 4L STXTE'6i? WISCONSIN 1 I County. as. Personally came before me, this - day of 19 the above named to me known to be the person- who executed the foregoing instrument and acknowledged the same. This instrument was drafted by i Ralph E. Senn, Attorney Notary Public County, Wis. ii River Falls, Wisconsin 54022 The use of witnesses is optional. My Commission (Expires) (Is) I Names of persons signing in any capacity should be typed or printed below their,4m. watu'515 j KGMNIaComprq® WARRANTY DEED-STATE BAR OF WISCONSIN. FORM NO. I - 1971 8°° ~ • i 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 systerrr; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OT€'-:R SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. l L u ~ the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MATE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A sep& -e sheet m,- , ' °--1 if desired; 8. Make sure your b ark and vertical elevation reference point are clearly shown, and are permanent; 9, Complete all slate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropri 10. If the information (such as flood plain, elevation) does not apply, N.A. in the appropriate box; 1 1 . Sign the form and place your current address and your certification t- _jmber; 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 _ .5,, t--t 10") BR -Bedrock cob Cc (3 - 10") SS - Sandstone gr Gra7 . I (under 3") LS - Limestone "s - Sand HGW - High Groundwater cs Coarse Sand Pere. - Percolation Rate coed s - Medium Sandi W - Well Is Fine Sand Bldg - Building Is Loarny Sand > Greater Than mss(- Sandy Loam < - Less Than *I - Loam Bn Brown *sil - Silt Loam BI_ Black Si - Silt Gy Gray *cl - Cka L im y Yellow sci S, y Loam R Red sicl - S Loam mot Mottles sc - Sal ~i Clay w/ with sic - Silty Clay fff few, fine, f6 ~c; - Clay cc - common, pt - Peat rTlm - Many, m Muck d - distinct. - prominent W - High wa Six general soil surface wr, - i for liquid waste _i sal BM - Bench Mark VRP Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county orthe Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit's lication must be submitted .r the appropriate local authority in order to obtain to permit, T it must be obtained ar, p ? prior to the start of any construction. I. . 7 P•4(rE- / of 2 A4G~-5 . DEPARTMENT OF y • REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 7969 LABOR, HUMAN AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: IV -1 SECTION: HIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 05 . ~4 y /T28'N/R 19 E (o TOWNS 7- COUN 6V- (PD/v OWN-TO' ffU jER'~NAME: G L MA LING ADDRESS: USE /1 N DATES OBSERVATIONS MADE I NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: R LATION TESTS: 0~ esidence z A/ ❑New Replace I a_~~_ f» ? 9-1 -P3 RATING: S= Site suitable for system U= Site unsuitable for system ~Itl t` lv _ SU~ s1/~~ S CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOL TANK: RECOMMENDED SYSTEM: (optional) /S-,fQ. F7- OS au ~~~~~-~T: - sHAiow If Percolation Tests are NOT required DESIGN RATE: ~QSS I If any portion of the tested area is in the 2j under s.H63.09(5)(b), indicate:/jQ0p Floodplain, cate Floodplain elevation: I,o A PROFILE DESCRIPTIONS 41J CT. BORING TOTAL DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) • 6a' d,N/-;V- S'/ , /.67' /34-S-"4 , 4/67' AIw-tAox•J e . B- s ' ' / 7 ' D~,6N. S:G , /,1 f ' /.~~1 • ,S'iG , .5~~ ~ '`'i X . o~c wi B- Z 17.0 7&,36 X40-- >7o TAN L$ ~.tv. ;~,4. IS fti. Sz- v sM Yq„W", B- / s sEC w 5',.t 133 64. s.?. 072 ply- OC- 3 7.0 . B-I S e- 1 0, Al"A013 /-J 164 A, A2 PERCOLATION TESTS OF ~it~• S• TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATPER INCHES NUMBER IN AFTERSWELLING INTERVAL-MIN. PERIOD1 PERI D2 P R D P S P_ _ ,67 137/ ~,a P- 3. o P P- 2.7 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 referen&-points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 1 ~ TTQm or- /3" C~XG~f (J/¢T/D.(J Ata 4_ SYSTEM ELEVATION 47Y4CrLY 76 -z'Ti'C, -4- Q_. _ - - r -7- _ l _T 11 . [ i 3 ~ i t i 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in 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 (print : TESTS WERE COMPLETED ON: HOMESITE TESTING CO. y_/- F-3 ADDRESS: RT. 3, O*NEIL Re*[) CERTIFICATION NUMBER: PHONE NUMBER (optional): Soo WIS. 54016 5_5 =oiYrZ 3 co - CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - s y INSTRUCTIONS FOR COMPLETING FORM 115 - SRD - 6395 To be a complete and accurate soil test, your report must irreau(1e; 1. Complete legal description; I 2. The use section mList clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or cornrnercial 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 abbreviat':)ns shown here for writing profile descriptions and completing the plot plan; 7."E A LEGIBLE Ali n accurately locating your test locations. Drawing to scale is preferred. A sheet may be usf desired; sure your benchmar. and vertical elevation reference point are clearly shown, and are permanent; S. C mplete 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; 1 1. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR I'ERTIFIED SOIL TESTERS Soil se, a ' Textures Other Symbols St - c.,_ne (over 10") BR - Bedrock cob Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone ~s - Sand HGV)J - High Groundwater es- Coarse Sand Pere Percolation Rate tried s - V iiirrn San(.! W - Well fs "and Bldg - Building is E_ ar:-y Sand Greater Than ~sl - `y Loam Less Than *1 - Lc, w Bn - Brovvn *sil - Silt Loam BI Black Si - Silt. Gy - Gray cl - Cl a, 1 r i Y Yellow scl - S - Loam R Reel sicl - Sil~ _ n mot - Mottles sc - S w,' - wi ; h sic - Silt -1 fff - fin: , Y c - Clay cc - common, . pt Peat rnm - Many, medir_ in - Muck d distinct p prominent HWL - High water level, neral soil textures surface !r {cidid waste disposal BM - Bench N', VRP - Vertu Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary hermit must be obtained and posted prior to the start Of any construction. , ,q0-C z of z RW 5- DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INQUSTRY, 1 G DIVISION LABOR AND t PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 'HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOT NO.: BLK. NO.: SUBDIVISION NAME: LOCATION SECTIO%t Z N/R 1 f)r (or OOWNSHIP/MUN ~ e~'~W/e COUNTY: - OWNER'S BUYER'S NAME: MAILING ADDRESS: S0 •Cio/K .v 13 Z- IRT / 1/,4//E 11,1fW /0• Ahx-~XTS &/1' . USE DATES OBSERVATIONS MADE I-PQ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PR FILE DESCRIPTIONS: PERCOLATION TESTS: Residence N+ ❑New Replace I RATING: S= Site suitable for system U= Site unsuitable for system Yes C7,0 ' " C C/Jl~v CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) $ ❑1I CZS ❑U Q$ ❑U ❑ S ©U ❑ S ©U sea- / If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 1/1 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) • 4 -2 ' Qu . S,'L / /l(o' 3, o o f PA) 7)..4- s . , 7 . ~ 7 4.4 S,c L B- - Fr B- herivr 7- 5-F B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PER PER INCH P- P- P-CA Is PA_ 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 b"- t /V I i I a ~ IE t 4 1 i I t i t t ~ EIE ~ 3 3 E E I ' _T J /2~• 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 (print : HOMESITE TESTING CO. TESTS WERE COMPLETED ON: RT 3y O'NEIL ROAD ?-I-F-3 ADDRESS: CERTIFICATION NUMBER: PH0 E NUMBER (optional): H6D;ON, WIS. 540 4 5_r _ 02 V F2- &O - r/ CST SIGNATU E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - -REP6RT ON SOIL GORINGS PERCOLATION TESTS 115 PLo.r PLAM PRoj-Ec i r. O. iPo/3 ~~rs~ Wis. pA rE 5-q4, I -,P,3 HOMESITE TESTING CO. R-3, O'%NEIL ROAD BOB UJr,R ' c;iA allUS N, WIS...._ 54016 e 5 7- SS- aZ y~Z PROPOSED HOVSE mosr LIE Z~ FT o~ MORE P~0~1 •3L~ TEST f~,PE~S, PRo POSE D W ff u M V5r or ,So FT. da° MDiPF A&M TE°sT • = eAcellbr Pars u~ = zr',srml U- L el-l- i( % Aeve- /oeo-lowf = N.4.vp fio9,r PE0 " S4ovEL Bo e5 r = Yow;z . 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