HomeMy WebLinkAbout026-1110-90-000
0 C~Nt 2 3 0
c 3
V
m
cn -1 7 Z O A N eE O•
~ fl1 3 N O O 00 N Sr W
co z c~i m m 3 °
C ~0 70D o
Vt Q 7 M N L L. a~ 0
N° CD 3 rn o o
l o~ m
a V (~1
I~ 7 y N n O Q
O ~ O
v cn ~ D D a ca
m (D N a w
v, W
3
CO
a O V
CD F~ cn A Z
i
Z ~
° co -4 ;0 CO)
0 r- CA 0 ? ' T
S w N •
oz 0 0 0 7
_ T
<
N
C',
0 .1
CA N ~ v fD
CO)
' 3 v v o
o (D yo o 0
d V ;
< rw+ R
N m
N
a <
z oo z CD o
O D a ~r
0 =r
N
CD
w C
C fD N
CD
W a
Z 0 + i CO)
A Z (D
v) C ~ n
a~ a A (Z 7
o
Z
oo M m wo
a co " Z
c cn
3 rn OD
CD A
W d
O O N n 3
C fD Q
7 N CD
fQ. O a !A O T
w .10 N C
v' V, fD Z a
CD w + p
3 m CX N
o:0, o
°om
y
5
m o a
J X n
~ C y
Sr 7 y A
CD (O O C
n y 7 N
w D CD * N
0 o O
H
CD X •An.
o ,b w
CD do
CD
A 0
°o O ° b
Parcel 026-1110-90-000 05/25/2005 03:06 PM
PAGE 1 OF 1
Alt. Parcel 4.30.18.626 026 - TOWN OF RICHMOND
Current `X, ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
MOELLER, DIANE C
DIANE C MOELLER
1742 MARGARET ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 1742 MARGARET ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 2573-VIEBROCK'S RIVER VALLEY VIEW
SEC 4 T30N R1 8W LOT 27 VIE- BROCK'S Block/Condo Bldg: LOT 27
RIVER VALLEY VIEW ADDITION
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 918/68
07/23/1997 439/372
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/20/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 56,300 116,700 173,000 NO
Totals for 2005:
General Property 0.000 56,300 116,700 173,000
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 56,300 116,700 173,000
Woodland 0.000 0 0
Credit:
Lottery C Claim Count: 1 Certification Date: Batch 221
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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 distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: y Trench: ;Width : JL enith: Number of Lines;/ ~ Area Built:_
Fill depth to top of pipe: "Z2 /1 l
/ r( I
Number of feet from nearest property line: Front, O Side, ® Rear,O1?
Number of feet from well:
i
Number of feet from building: - 42
(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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
I
Inspector:
~~L
Dated: - Plumber on job:
License Number:
3/84:mj
e
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER / TOWNSHIP aib SEC. T_N-R_W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT 43 1 LOT SIZE
Ll~
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
G I
c
1i E
s
i
I
S,24_ 4
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used -
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front, (IN
Side 0 Rear, O ~z feet
.From nearest property line °Front10 Side,W Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic to k)
SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
M1A0%Of4, W 153707 ~rp~
NEB;, SE'-R18W UCONVENTIONAL ❑ALTERNATIVE state Plan 1. D. Number:
(If assigned)
Town of Richmond, CTY Road A❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
Conv. Replacement
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION DATE:
Jim Moeller Route 5, New Richmond, WI 54017 L7'1s-,'7 r
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.. County: Sanitary Permit Number:
Calvin Powers Jr. 1563 St. Croix 99086
1 i 1
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LAB:y OCKING COVER
PROVIDED: ROVIDED:
❑YES ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: DING: VENT TO FRESH
ALARM. FEET FROM LINE AIR INLET.
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: JPUMP 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 moisture at the depth of plowing LEN(,TH 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:
PIT FINSIDE DIA #PITS' ILIQ O TID
BED/TRENCH WIDTH: LENGTH FTRENCHES DISTR. PIPE SPACING MVER
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELEV. INLET ELEV. END: PIPES. FEET FROM LINE: AIR INLET:
NEAREST--•
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS.
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. 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: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: [BSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
3 ❑YES ❑NO ❑YES ❑NO NO,. NEAREST
i
I
Sketch System on -~i Retain in county file for audit.
Reverse Side. <
t; ~ ~ SIGNATURE: TITLE.
Zoning
DILHR SBD 6710 (R. 01/82) Administrato
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number-of bed -
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained: The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owners name and mailing address. Provide the legal description where the system is tQ 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% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump -
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984; 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Grouncl~
water
included the creation of surcharges (fees) for a number of regulated practices which Wiscorisin's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried ensure
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
G
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03/86)
SANITARY PERMIT APPLICATION COUNTY a
T DILHR In accord with ILHR 83.05, Wis. Adm. Code v '
STAT NITARY 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 nJ NO
PROPE TY OWNER PROPERTY LOCATION
1/4 1/4,S lyl 110 ,N,R E(or~
PROP RTY OWNER'S MAILING ADDRESS LOT NU ER BLOCK N MBER SUBDIVISION NAME
CITY, STAT ZIP CODE PHONE NUMB R CITY NEAREST ROAD, E OR LANDMARK
❑ VILLAGE : E°
A/kk t-%4&/7 ( 7/p TOWN OF* eJ66~nmw II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public (Specify): A// //v
III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. ❑ New b. 50,j 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. 141 Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. seepage Bed b. ❑ seepage Trench c. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4.1 ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet 9Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank - F-1 El
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation oft rivate sewage system shown on the attached plans.
Business Phone Number:
t): i Plu is Signatur . (No S mps) MP/MPRSW No.: Lj ( Z/_~_
Plumber's NamInix"'t
O[ ~S 3 Plum er's Addre4 / treet, Cit tale, Zip Co(
ie): Name of Designer:
D' /.Wt
VIII. SOIL TEST INFORMATION
Certifi d Soi Tester (C Name CST -
CST's D R S (S reet, City, tate, Zip Code) Phone Number:
i
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
XApproved ❑ Owner Given Initial rcharge Fee
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03186) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
i
R ~
5 f
•
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
Location of Property SE Section , T_50 N-R W
Township LG1~1r111c1,~
Mailing Address 92Z E7 E=X LOA2
lbw R, tct~nr~ IlVi .
Address of Site
Subdivision Name V 1 AVAujiy VK--w Ammaam
Lot Number
Previous Owner of Property WAY" ?4 ~12fta j
Total Size of Parcel w vr2A
Date Parcel was Created
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes X_ No
Volume? - and Page Number ~2-aGj as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
(AWwarranty Deed wh ch includes a Document number, volume and page number, and the
Sea a 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) ceAti6y that att statements on this onm alte tAue to the but o6 my (ouh)
knowledge; that I (we) am (ahe) -owheAU th.e p&open ty du ch ibed in th.i,a
.in6onmati.on 6oAm, by vi tue o6 a ' anty deed &,econde&,in the 066ice 06 the
county Regihten o6 Veed~s ab Vocume SSIGII and that I (We) pnebentC.y
own the pnopoaed bite bon the .6ewage ~ I (we) have obtained an
eabement, to nun with the above debehibed pno bon the con'stAucti_on o6 said
6 ye.tem, and the aame had been duty tecoaded in the 0 66.iee o6 the County Reg.i a.teA o6
Deeds, ad Vocument No.
(10" ALMA
fURZ 3 Oi OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
r
DATE SI D'.. DATE SIGNED
at
r z
17
x r V 1. 'r. ;6h '~}r f! f
'•R~ 3 0
49
OYa cOW040 t
Ilawu~_deacrrbrA realsiN~/.~~v;, 1~1Y11Mr~llt~t•ot~Kwrii~ ; ~ , -~t'~,
Lot Z7, .V
R Add* ti*4 4t@ Tq~ hi
K '9' •{"i'j";_ `emu
a T -~.,wr+w~-ekA~+P+*i.t~ ~1J'Il• ]i ~.:,T,
Ls " -tit, • - f~y ~P
t
a C. Wi
0~ "T 97m
t Ki f' ` ~1a'$it iii~lr .tl
$
Zt-
2 SS" 5 1 ~s i P
j~~~ny~' y~~j. pr~.~. Ji4 , lA TYPii• 4 i ~ t
i- #~_~f
• '""ati~ Z~, i. 3!~ J ,Y 1:-. ~s a
a°
iiilll¢fi 5 ; _ 7
-TT
z
' cn
H
' a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
H
OWNER/BUYER G • /Y►l.L.~l2
ROUTE/BOX NUMBER FEOX 10442 Fire Number 11!Lsp)
CITY/STATE UEly ZIP
~ t!.NN'kD~tD } ~=z 2-'f 7
I
PROPERTY LOCATION: M~ 34, 14, Section 14 TSo N, RI_W,
Town of {G/k~lyD St. Croix County,
Subdivision Vie ~4rx~t_j"~e~u Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
f 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 s-yste-ms__agree to keep their systems properly
~vo
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. H
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
r+
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.
I '
YS
DAT
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.
A -tUCTIONS FOR COMPLETING; FORM 115 - SBD - 6395 ,
To be a cornplete and accurate soil test, your report must include;
1. t 1_ te legal description;
2 > section must cl, ly indicate whetl < this is a residence; or commercial project;
1 'UM number of -ams or cot use planned;
4, )Vol t system;
5. t the suitabil ling boxes. A 1S SUITABLE FOR A HOLDING TANK ONLY IF ALL
uYSTEMS A~_ 'ULED OUT BA ON SOIL CONDITIONS;
6. PLEA : use the hk: shown here for v,vriting profile descriptions and completing the plot plan;
7. E .A LEGIBLE n accurately locating your test locations. awing to scale is preferred. A
s sheet m~.y 1. desired;
-e your benL and vertical elevation reference point t c hown, anti are permanent;
lete all appropriate boxes as to dates, names, addresses, floo data, percolation test exemp-
ppropriate;
21 information (such as flood plain, elevation) does not apply, in the appropriate box;
11, tf,, form and place your current address and your certificati(
1; gible copies and distribute a$ required, ALL SOIL BE FILED WITH THE
i AL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
AF . flATIONS _ CERTIFIED .L TESTERS
Soil Separa _ xtures Othi ` ymbols
t - Stc: 1r=i BR
SS
LS
HC'.
1 _ Hi
R~r
y
- nF R
Lt e"n not 3
a
TO a Tl f nest
A
'i
i 1
_ i
U
I
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 DIVISION
P.O. BOX 769
LABOR AND . , PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS (H63.090) & Chapter 145.045)
LOCATION: T SECT ON: i TOWNS IP/ LITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
N/R ' (o
Alt
COUNTY: 1UWNER'S/BUYER'S NAM AI NG ADD ESS: c•
USE DATES OBSERVATIONS MADE
NO.BE RMS.: COMMERCIAL DESCRIPTION: PROF LE DE RIPTIONS: E AT ON TESTS:
®Residence / ❑New Replace. ~ 19--7
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: IMOUND: f~~ND-PRESSURE: SYSTEM-IN-FI OLD G TANK: REC MMENDE SYSTEM: (optional)
1,771 SDU MSC~~ ®VE]U0SZU ES 1-4,4 Z
If Percolation Tests are NOT require DESIG RATE: If any portion of the tested area is :in the
under s.H63.09(5)(b), indicate: , Floodplain, indicate Floodplain eltion:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH tZ, ELEVATION OBSERVED EST. tGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B _1i
113- X",
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD 1 P)ERT D2 P ! PER INCH
P_ I
S ! :a
P_ o "
P-_
FH
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.
`13
SYSTEM ELEVATION
4WI
o
3
i
i
ft~- 4r
N
I ,
s E
41-
t
i
I
I
I
1, the undersigned, hereby certify that the soil tests reported on this form were made by"-me i acc ith the procedur and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the be knowledge and belief. <
NAME (print : f TESTS ERE COMPLETED ON:
ADDRESS: CERTIFICAT NU BER: PHONE NUMBS ; optional):
~ CS TU
,
U
-N: Original and one copy to Local Authority, Proper Ly Owner and Soil Tester. i
'?/82) - OVER
/ /C~~/%~di►/.D
_i
C GI ~l f
.0 \
~ p
L/I
t
i
PAGE OF
CrUSS S.cc~lon o~ A zci) J~~sFt°n~
s . Frooh Air Inlol• And Observation Plpo
Ak. ~ Approved Vent Cap
Mlnltnunt 12 Above
Final Grade
20- 42' Above Pipe -4* Cost Iron
To Final Grade Vent Pipe
Mmeh "my Or Synthetic Covw"
Yin 2r Aggregate
Over Pipe
Distribution - Tee
Pipe o
G" Aggregate o Perto+aleJ PIPS Bsl:vr
Beneath Pip* -Compiling Trminetlag At
Dallas% Of $16140
~.1~~•.}ton
. vii.
SOIL FILL
DISTRIBUTIOVI PIPE APPROVED S4jMrETIC COVER
/ MATLRIAtr OR 9" OF STRAW
rOF j\4GREWE J OR MARSH HAd
(e, OF 12-Z~/2 AGGREGATE
DIS"rRIgUTIOM PIPE TO BE AT LEAST INCHES BELOW ORIGIUAL GRADE
Ak)t) AT LEASTLO IIJCFIES BUT AIO MORE THAI) X12 IMCNES BELOW FIAIAL GRADE
MUMM MrH OF EXCAVATI60 FROM OKI& WAL bKAIDE WILL BE IMCNES
WNIMUM W" OF EXCAVATION FROM. V*IGIMAL GRADE WILL 0E INCHES
I
S16AIE0:
r
LICEMSE IJUMBER:
_
1 DATE:..
110