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CC O G ,I N C I Z G o N I • Q c. e- s 1 a I ti c N I a a v I a K 1 O CD 0q is A O I 0 a I oo c- y • 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, ()Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan) . SOIL ABSORPTION SYSTEM Bed: ( Trench: Width: a Length: 99 Number of Lines: „2 Area Built: 91S Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,Pt Number of feet from well: 7/4 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: /-L;212,87 Plumber on job: & I,E,(S License Number: Arl'S 3/84:mj f Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 4,J jc,a/rk TOWNSHIP ;e4/010 SEC. /,j T34 N-R /. ' W ADDRESS 2,? ST. CROIX COUNTY, WISCONSIN ) 41 M)[s-0/7 SUBDIVISION 4/1 LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of II,HR 83 "SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM-- 0/'A /6v 4 / / i' 7/D t;r7-*# .rs' INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used API,J lh ,,tijx'' cf Elevation of vertical reference point: 4,2264 Proposed slope at site: n SEPTIC TANK: Manufacturer w Li uid Capacity: U JLg.•L / Number of rings used: . Tank manhole cover elevation: Xl5 Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,(Rear, O //_S feet From nearest property line Front,OSide,O Rear,® //lc feet Number of feet from: well ,/// , building: /g (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 PRIVATE SEWAGE SYSTEMS DIVISION R.O.BOX Y969 BUREAU OF PLUMBING MADISON,WI 53707 NW1/4,NW1/4, S13,T3ON-R18W )171 CONVENTIONAL E]ALTERNATIVE - State Plan l.o.Number: (If assigned) Town of Richmond II]Holding Tank ❑In-Ground Pressure ❑Mound 160th Avenue (e7w • NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT DATE: �� Marvin Boucher Route 2, New Richmond, WI 54017 1/-'e.) / 8 7 g` CX 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 92490 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV: WARNING LABEL LOCKING COVER p, )S,y PROVIDED: PROVIDED: (r1 I �� 1 DYES ONO OYES I:2 NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF 'ROAD: PROPERTY WELL BUILDING. VENT TO FRESH �( �^ ALARM: LINE / ` ' ' AIR INLET: OYES LAINO LI ` ' ❑YES ❑NO NEAREST > 1 \J �f DOSING CHAMBER: • MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER . PROVIDED: PROVIDED: OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF I PROPERTY WELL (BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM (LINE AIR INLET: PUMP ON AND OFF) OYES ONO NEAREST----��� SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH. DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN • CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA. SPITS LIQUID • BED/TRENCH (,� TRENCHES !! I TERIAL: PIT DEPTH- DIMENSIONS 12 1 S co GRAVEL DEPTH FILL DEPTH DISTR.PIPE 'DISTR.PIPE (DISTR.PIPE MATERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH • BELOWPIPE: ABOVE COVER: ELEV.INLET ELEV.END: PIPES. FEET FROM LINE Q 0 AIR INLET. l b D 1 94,02 I A 3.f.3 2-1 t-G'� NEAREST- 5 i 31 f • MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ❑NO COIL COVER,TEXTURE. PERMANENT MARKERS. OBSERVATION WE LLS LIVES 117 NO LIVES CI NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER. EDGES: OYES LINO OYES ONO OYES 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 ELEV.. ELEV.. DIA.-. ELEV., PIPES DIA.. ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS LIVES El NO ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY 'WELL: BUILDING: FEET FROM LINE: % "`) LIVES ONO OYES 0 N NEAREST lv I 11 ic-:--,„,... c . _......__ ii„....\______ . • ,,.4. —H- , f_._.___________ , , . „ , ,.c., (, n. oc .... ,,,.. , Sketch System on Re .. in-E file for audit. Reverse Side. SIGNATURE: --,.-�TLE: DILHR SBD 6710(R.01/82) -/� / Zoning Administrator 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, 608-266-381.5. To be complete and accurate this sanitary permit application must include: I. Property owners name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 81/2 X 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground agar included the creation of surcharges (fees) for a number o' regulated practices which Wiscor S#1 ' can effect groundwater. The surcharge took effect on July 1, 1984 All of the water that buried reasure used ire your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. through these surcharges are credi"'.ed to the gr:)unr water fund adrninis ;®; .'� "1_'*' ?re. t',,.' z r4,_ frlvnt of E'tiatU"5i 1-i?SOL:rCe=,. These funds are i 'P,C`. ",C)r monitoring group O- , :-tt ,: wG,a, ".:')ntamlrlatli;il iri." ,Stigatii)nS and establE.,ha;c nt _;, Se3:id[t'"dS S .'rti` prc,tecng. ,RE)-F,398(8.03,66) SANITARY PERMIT APPLICATION COUNTY DILHR In accord with ILHR 83.05,Wis.Adm.Code C RO/x =. °s...,.,...,,o.,.� STATES T II ' RY 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 IS NO APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE El YES Y&NO PROP RTY OWNER LOCATION OC ATION PROP RTY $gdQZ4&,C .Alsf/ '/a/`/jU 14, S/3 Ti N, R 18 E (or)uu'' PR E TY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NBER SUBDIVISION NAME . /1 CI STAT ZIP CODE PHONE NUMBER ❑ CITY NEAREST OAD,LAKE OR LANDMARK 41)7' `` �,/_/ ❑ VILLAGE 'Zit) t4�44/ 1S 7 V/ 12/`7�7`r` ® TOWN OFD . 7a04119dlJ i//D d( c — II. TYPE OF BUILDING OR USE SERVED: ' 67 —/ a - /2 if 1 or 2 Family 3 OR �(Specify): Number of Bedrooms o a y /��j III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. X New b. Replacement c. I 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. 0 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. 0 Seepage Bed b. ❑Seepage Trench c. ❑Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): / . ?C 9 /i_?c )1 ?c 93.a Feet :11 Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total #of Manufacturer's Name Prefab. Fiber- Plastic Exper. Con- Steel INFORMATION New Existing Gallons Tanks Concrete glass App. Tanks Tanks //77 strutted Septic Tank or Holding Tank /0190 „moo / �A A-,(2i m 1J ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation - -- rivate sewage system shown on the attached plans. Plumber' Name(Pr' t): 9nber's Sig. o tamp ) MP/MPRSW No.: Business Phone Number: Plum r s Address( reet,City, ate,Zip Code): Name of Designer: Ng VIII. SOIL TEST INFORMATION Certif Sol Tester(CS Name CST# din) �64e ck ..S.:5- CST's RESS( reef,City, fate,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) N.Approved ❑ Owner Given Initial Su harge Fee Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY PERMIT 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 a v..vt. Q e y�k e 1- Location of Property illAS 1 N W 1, Section 13 , T_R a N-R h W Township (lJ L/l Yyc t--►^d Mailing Address k R tc.1 ,•• j w L s c sa i Address of Site RR 1 • A24-3 w c s c 5% 1 i Subdivision Name r k i elS Lot Number / Previous Owner of Property 0-06n }t o k� n. $ Total Size of Parcel �/ Date Parcel was Created Are all corners and lot lines identifiable? 4 Yes No • Is this property being developed for resale (spec house) ? Yes / No Volume 277 and Page Number 15'2 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) cehtti6y that all 4tatement4 on thi4 6okm cute .lcue to the but o6 my (oun) knowledge; that I (we) am (are) the owner(b) o6 the pnopeh ty deg ch i.bed in th,i a .in6onmation 6onm, by v.i .tue o6 a walvcan yjf ed neconded in the O66Lce o6 the County Reg.c.aten o6 Deeds a3 Document No. v ,7 ?Jr--; and that I (We) pneaentey awn the pnopoded date bon the aewage dispodat a btem (on I (we) have obtained y e an easement, to nun with the above de c ibed pnopeJity, bon the cond.ticuction o6 said system, and the dame has been duty neconded in the 066.ice o6 the County Regi4ten o6 Deeds a6 Document No. pi-6u, 26,1,9_, SIGNATURE or OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H STC - 105 9 H SEPTIC TANK MAINTENANCE AGREEMENT • St . Croix County OWNER/BUYER 00,1% 1 l`l Y1 Q.A.S.„ 2 r � ROUTE/BOX NUMBER f? -Z Fire Number CITY/STATE �p,�J 11 t any+-mod LA-4-` ZIP silo( 7 PROPERTY LOCATION : /O - 1, MAJ 14, Section /3 , T .36 N , R /9 W, Town of edorwtro_j , St . Croix County , Subdivision , Lot number 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 . HH I/WE, the undersigned,, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth , herein, as set by the Wisconsin Depart- w 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 . SIGNED I V a -K-, DATE — - 8- 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 . DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 424295 - REGISTERS OFFICE @OOK �. t.' 5 .� ST. CROIX CO., WI& Rec'd. for Record this 9th This Deed, made between _hn..M.....H.apkin ..ancl... ': day of Apr_ A.D. 87 -Janet-..G-....liopkins,..._husb-and...and.._wi.f e., I — at 8:30 AIAL , Grantor, ; James O'Connell and 1Mar-vin--E_---Boucher••-and..Che.ry.L••R_ --. IsiW. M sods /f/ - IY. Boucher-,.-.h-us-band...and--wife_,.-.as //Q//�� q'�. a�4 su-rv-ivo•rship--maarita-l- property-, deputy , Grantee, Witnesseth, That the said Grantor, for a valuable consideration ij i lI RETURN TO f' conveys to Grantee the following described real estate in S-t- -.Croi 7C li County, State of Wisconsin: I j li Tax Parcel No: Ii Lot One ( 1 ) of the Certified Survey Map filed in Volume la of Certified Survey Maps on Page /793 as Document No. 4 .1 41a 9 9 being a part of the Northwest quarter of the Northwest quarter (NW; of NW;) of Section Thirteen ( 13) , Township Thirty ( 30) North, Range Eighteen (18) West. TRANSFAS $ FEE This is-..not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except , and will warrant and defend the same. i Dated this 27Z' day A v of p-C i.1 , 19 87 9--'61-4)-• ?"1") ' Aivid-12'-'"'. I IcLZ,te --/*(SEAL) )!.. / (SEAL) Jahn.--M.---Hapkin Janet-.G_...Hopkins (SEAL) (SEAL) * • AUTHENTICATION ACKNOWLEDGMENT Signature(s) af...Jflhn. .M.....Hopkina STATE OF WISCONSIN and.._Janet._G.,...Hopki.no 1 ss. Cq� County. authenticated this .1T11..Gay of April , 19_.8.7 Personally came before me this day of �� _ . , 19 the above named * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Scats.) to me known to �,': o be the person on who executed the foregoing instrument and acknowledge the same. j: THIS INSTRUMENT WAS DRAFTED BY BAKKE,.••NORMAN..&..S_CH.UMACHER.,...S.. C. * 1200 Heritage Drive New Ri' -hm0iid-""""WI-54-0I? Notary y Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 19 ) *Names of persons signing in any capacity should be typed or printed below their signatures. INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; • 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10") BR -- Bedrock cob Cobble (3- 10") SS — Sandstone gr -- Gravel (under 3") LS — Limestone 's Sand HGW — High Groundwater es _. Coarse Sand Perc — Percolation Rate med s -- Medium Sand W — Well •s — Fine Said Bldg — Building is — Loamy Sand > — Greater Than 'sl _ Sandy Loam < -- Less Than — Learn Be -- Brown "sil — Silt Loam BI — Black si — Silt Gy — Gray "cl -- Clay Loam Y -- Yellow scl — Sandy Clay Loam R — Red sicl -- Silty Clay Loam mot — Mottles sc -- Sandy Clay Wry — with sic — Silty Clay fff -- few,fine, faint — Clay cc — common,coarse pt — Peat rum -- Many, medium m — Muck d — distinct p — prominent. HWL -- High water level, Six general soil textures surface water for liquid waste disposal 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 or the Department may request var ificatron of this sail test in the field pr ior 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 perrnit must be obtained and posted prior to the stare of any construction. • DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION P.O. BOX• j AND PERCOLATION TESTS (115) MADISON W 53707 HUMAN HUMAN RELATIONS (H63.09(1)& Chapter 145.045) LOCATION: SECTION: TOWN +IP/MUNICIf ALITY: LOT NO.:BLK. .: SUBDIVISION NAME: /��1 '44J'/ / /T N/Rjg E (org1 �"/0/In ,0 its// COUNTY: OWNER'S/13UVER'S NAME: MAIL G ADDRE S: /t. '� . r� MO /ice i _ If i Al USE DATES OBSERVATIONS ADE NO,BEDRMS.: COMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence J, New ❑Replace _ 7, 3 .7 fr7 -CO U RATING:S=Site suitable for system U=Site unsuitable for system ,V4A Se _Is y�,e,Sz--;4194jy7 CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYST N-FILLHOLDING TAN RECOMMEND SYSTEM: ptional) xis ❑U gs ❑U Zs DU ❑sLU ❑sLU , divdt��4,41 If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: �/ a,1,-c. 3 Floodplain, indicate Floodplain elevation: a/1 /" ��//�y�J PROFILE DESCRIPTIONS �J/ 'r BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH . NUMBER DEPTH-M. OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- / i 4 i m:a B- IM 4 11 IFINIM "4. • . IE, : :Is , r PM - . I_ 1, A ,/ . . 0...:1115 IINEEIMIPPIIIIIIMII6-.'r /4'. ` - .GS,; I, 44 . / B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 1rttelES AFTER SWELLING INTERVAL-MIN. PERIOD/,2, PERIOD 2 PE/IOq 3 PER INCH P- / 13 14A/1E _'d /7j 7�/ _9t 9 P-a -53 if/©N� .3O ! / A .. • 8 P-3 ,S 44,v2 ?O /./5‘ / / - 1f, 1.P _ P- /eteeilEsr-1275 2- 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,surtace elevation at all borings and the direction and percent of land slope. /j5' 4),E i,o d SYSTEM ELEVATION 95 /n I X rti ' <1 '�,Js . ..._ ._1 i , /� i 1 ' i 5 _i TN rte..-.... M -,0 ---I-- -f i I 4 .cayG I 1 a t� � i _ , 5 ; � � , [ 41 ; 1 , .1„ 43:„„ i : 1 1 1 ; ; i F-e----ral-' Iry I• 1 i 4/a: 7 1 / . i 1 � 1 1° I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with tih procedures and methods specified ii 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 prin : TESTS.W RE COMPLETED ON: fl)te,e'S 1.le -1---cg 7 A CERTIFICATION NU,': -: PHONE NUjMBBER(-optional): -:,_ &e) /4.,‘,0,f)„0 /117- .5- .4./"7 L -5"---,..5:?/ i/c--( 2 ,3S- CST ON/ URE: -..iiiIIIIIC140- - .....■/. DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) -OVER - � y , /%/Jy� edb.0 &a 4/ i//mA'x7 � 7 14)61' /7 6,4na .o Elio sizx -/?:0 1 W /4s S6-"a'ia % ' Peit i9D®&n- 4 >//f%c =AA,t./,,,) e' ox'',)mss f�./e,o //=2O' se .4 43./e --5Liii 7 1- :• /, 4--r as/Jir) 4,64- cinl , ),* ' /S"6S 3' /to `/Adz B '3, \I% 4/4 69 0/ : , /a, i vi\I s/056 Atli-i _ i / . , /1945, ( . / --- --://17 -' '. ,' i / /1iitJIs(tll- / Ni i ....I PAGE OF CrU S S S zC 1. 1 0 O r /'1 ti) SySten1 4919 s„,/,,-4. 4.2 Fresh Air IMO' And Ob lion Pipe r� t m4) f Approved Vent Cop ��JJF Minimum 12°Above Si7 Final Grade 20-42 Above Pipe — D 4"Cast Iron To Final Grade Vent Pipe Marsh Hay Or Synthetic Covering min. 2°Aggregate Over Pipe (� Olstrlbutlon —Tee -• Pip. —'� 0 0 0 0 0 n 6°Aggregate o� Per/orated Pipe Below Beneath Pipe o —Capping Terminating Al Imes Bottom 01 Syctem PropO t P1n4-1 grhC\< c_ItJ•.� ion SOIL FILL DISTRIBUTIOVI PIPE 'iN,� A,PPROVEO S ETIC COVER. MATERI^I- OR 9'' OF STRAW Z"of MGR EGATE -� 11111411111111111111C4111•11114111111111//// OR MARSH NAy (o OF%2 21/2 tLE FEET, � �\ DISTRIBUTION PIPE TO BE AT LEAST 3Z) INCHES BELOW ORIGIIJAL GRADE AMU AT LEAST 20 INCHES BUT MO MORE. THAN H2 INCHES BELOW FINIAL GRADE timmuM Depni OF EXCAVATI00 FROM ORI&w+AL bRAK WILL EE 5 IIJCHES NuNIMUM °EPni OF EXCAVATION MoN•Itk14iMAL GRADE WILL BE INCHES SIGLIED: - it LIC ELI SE AJUMBER: DATE : (v ' (.?? 110 J