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HomeMy WebLinkAbout028-1009-20-100 ti o o 0 Mm 0 0 N ti i I �I OI 'O Z C li c O 3 Q I ax Z y C � � O d d M FN- U) IL m � c O G a � O v O Z c _ a�i Z o 0 fn H I N Z S E -2 "O N M N N � N f= � • d a� O L O O Q Q O U Z Z Z N NN _ 16 y IL 0 - O 0. r- 20 w d V N O O �w O 3 G G a N �J Z j m N N N E O Zo •N a Lao. a Cl o 06 0 tia' :� � =�� � � E o LO too m c a w d Q CA Q O x ° 3 m° y c oa FO- E c d u o CO - u a. o N < m O N 42 O �_ Q O O a O •O ' d o CO rn o Z Z � V w a EL m • C m .2 m 0 c E 2 c c A U a O U) U Parcel #: 028-1009-20-100 03/18/2005 01:33 PM PAGE 1 OF 1 Alt. Parcel#: 3.28.17.48B 028-TOWN OF RUSH RIVER 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 "POWERS,ADAM&ANN ADAM&ANN POWERS BOX 193 BALDWIN WI 54002 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description `50TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.066 Plat: N/A-NOT AVAILABLE SEC 3 T28N R1 7W SE SE 2.066 ACRES LOT 1 Block/Condo Bldg: CSM 7/1828 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 03-28N-17W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 782/02 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 6862 180,000 Valuations: Last Changed: 06/04/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.066 12,600 95,000 107,600 NO Totals for 2004: General Property 2.066 12,600 95,000 107,600 Woodland 0.000 0 0 Totals for 2003: !i General Property 2.066 12,600 90,000 102,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 215 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 PUMP CHAMBER f 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: Trench: Width: �� Length: Number of Lines: 0 Area Built: -7� Fill depth to top of pipe: U Number of feet from nearest property line: Front, O Side,A@ Rear,0 Ft . 72> Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: { V / � Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: `v 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: I Inspector:. Dated: - 3/- 7 Plumber on job: w License Number: j�'jP�s 32, ZyZ 3/84:mj Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP - '�' . g � SEC. T_N-R/;�' W ADDRESS ti ST. CROIX COUNTY, WISCONSIN SUBDIVISION � r LOT �I LOT SIZE lyh PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 50 T / 93 -T g/ , 3 i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: �Xz--� Proposed slope at site: SEPTIC TANK: Manufacturer: (.vim Liquid Capacity: '-Z")Vep gfT� v Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,Q Rear, ,! �6 7 feet From nearest property line Front 10 Side,QRear,0 z/_Q feet Number of feet from: well /( �, building: li"� - µ (Include this information of the above plot plan)( 2 referen 1EE imensions to septic tank) RE VERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LAPOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MA6'190N,UVI 53707 SEk, SEk,S3,T28N—R17W MCONVENTIONAL El ALTERNATIVE State Plan I.D.Number Town of Rush River (If assigned) Holding Tank ❑ In-Ground Pressure ❑Mound Oak Drive NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION d NTT, Adam Powers Route 2, Hammond, WI 54002 y- '?�''�7 J1 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: Roger Timm 3224 St. Croix 96051 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. T T ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO EYES ❑NO BEDDING: VENT DIA.. VENT MATL JHIGH WATER NUMBER OF ROAD: PROPERTY WELL: JBUILDING: VENT TO FRESH ALARM: FEET FROM.. LINE. AIR INLET: OYES ONO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER BE ODING: 11-IIIUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ONO ❑YES ONO I DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PR OPERTV WELL: BUILDING:JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) OYES ❑NO 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: i WIDTH I LEV)NG7y� INOOF pISTR.PIPE SPACING. COVER INSIUE DIA. #PITS. LIQUID BEf /TRENCH C� TRENCHES MATERIAL: PIT DEPTH. E�IMEN'�I�iNS GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DI STR NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER.JILEV ,N_E T 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- ❑YES meets the criteria for medium sand. TIONS MEASURED. ❑NO SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES 1:1 NO ❑YES NO DEPTH OVER TRENC7771-PTH OVER TRENCHBEO DEPTH OF TOPSOIL SODDED SEEDED. IMOYES ULCHED: CENTER. ES- ❑YES 1:1 NO OYES ONO ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER : h�ITR° CI'tf TRENCHES: ®IME 1,0 MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV.: DIA.. ELEV.: PIPES. DT: E1.EVAii61N ANCi ?5 f R�ti1)NF i�ORMTIO1*[ HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED F PLANS. ❑YES ONO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: (/- DYES ONO I OYES ONO NEARESTM C�(.1 15;.4n R"X1 LI Sketch System on 1 Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: Zoning Administrator DILHR SBD 6710 (R.01/82) INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: t 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 I criteria in the Wisconsin Administrative Code will be applicable; r' 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 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be I 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. Prcperty owner's name and mailing address. Provide the legal description where the system is to be installed- [I. 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 00y;,, 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 ate[ included the creation of surcharges (fees) for a number of regulated practices which Wisco C13t$. ° can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r AStiit, is used in your building is returned to the groundwater through your soil absorption e system or the disposal site used by your holding tank pumper. , . o 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) DIL R SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# Fleas/ —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 El (�,�r YES [ NO PROP TY OWNER PROPERTY LOCATION S T .49 N, R j (or W PROP TY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK ir UM13ER SUBDIVISION NAME Z CITY,STATE ZIP CODE PHONE NUMBE CITY ` NEAREST R AD,LAKEOR LANDMARK J Ci��.� VILLAGE: , ��� ar�� II. TYPE OF BUILDING OR USE SERVED: - Gbh Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1 1. a. I New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. Conventional b. El Alternative c. ❑ Experimental { I 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. Xseepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSO14PTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ''j / 5 3, -- F1 rFeet XPrivate ❑Joint ❑ Public CAPACITY VI. TANK in g allons Total #of Prefab. Site Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank G$D S Lift Pump Tank/Siphon Chamber ❑ 1 D ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumb 's Signature:(No tamps) MP/WPRSW No.: Business Phone Number: �✓ ,� 3Z- 7jz 3Z-l5' Plumber's (Street,City,State, ip Code): , Name of Designer: L5o 'p? .527 Vlll. SOIL TEST INFORMATION Certified Rester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Code) Phone Number: s#01'( 7/S 7 7 4, IX. COUN /DEPA M NT USE NLY ❑ Di approved S nitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) IX Approved F-1 Owner Given Initial /d0.00 Su arge 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 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 Ad i- N"-- &026L Location of Property �t �� , Section 3 , T o729 N-R / _7 W Township Hailing Address __QO y TZ 2 9 A Wo tid o ry a W S 9-4 o o Address of Site Qo otf 2 go s Subdivision Name _( M Lot Number / 1 Previous Owner of Property LL/Y/& 6hNSC>N Total Size of Parcel r;(, 0�1_ Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yeses No Volume 2- and Page Number 01- as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warrantq 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 (toe) CcAt-4y that atL 4tatement6 on this ohm ane true to the best 06 my (oun) hnowtedge; that I (we) am (ane) the owneAkf 06 the pnopehty dust i.bed in thin .in604nati,on 6o4m, by viAtue 06 a waAAanty deed neconded in the 066.ice 06 the Count yy RepAten o6 Uee6 ass Uoeument No. 7`/ ; and that I (We) phuentey oeun .the phoposed Aite bon the sewage dupoz bye em (o)t I (we) have obtained an easement, to nun with the above desehi.bed pnopehty, bon the eon,6tAuctti.on o6 Said system, and the dame hab been duty neconded to the 066,tee o6 the County RegiAteA o6 Veede, ae Vocwnent No. ) . SIGNATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) ?- 9- IOV7 "E SIGNED DATE SIGNED DOCUMENT NO. �—' WARRANTY DEED THIS SPACE RESERVED FOR REI ORDIND UAIA � �5 � STATE BAR OF WISCONSIN FORM 2—lgBg REGISTERS OFFICE ST. CROIX CO., WI& ..Elmer---Jnhnsgn..and..M�rzan...ss�hr ai�,._.hus alad...dad... ..Wife. ...... Reed. for Record this_�,h„ •--•---•••-•-----•. ....... day of June 19 ................. ...........................•----•--•.......----•- conveys and warrants to _.-Adam..PQw�ex g...d;1d.-A11A-.-4W4�,�.....-- 4:3 IIA� .husband..and._Wife., •--........•---- M 04 WWI •••--- RETURN TO ......................................... ........... the following described real estate in .......- ............County,......... _....� QIX — `-- -- — State of Wisconsin: _ Part of the SE 4 of SE 4 of 3-28-17 described as Tax Parcel No; ........................ follows : Lot 1 of Certified Survey Map #426690 as recorded with the Office of the Register of Deeds, St. Croix County, Wisconsin, on 6-8-87, in Vol. 7, Page 1828. '�ANSAAn/� FEB III I I This _'-a--aQ f----,---- homestead property. (is) (is not) Exception to warranties: I, Dated this �� day of +� Ile .... ... ... - -• 'lk.�! -•.. ..... . •-- .......... .. .. -.. ., 18.17.... - --- •-------- _.-(SEAL yLi ----------------------(SEAL) E.].lae-lt..Ja1i on-- •-•------ -•• - ---�---,--�---�----------P-- •----•--•---•.....------•--•--.....•-•--• . --.•------. ---•• •.• SEAL) f i i ...........................(SEAL) N�axi,an_�Iohz�a ... AUTHENTICATION ACKNOWLEDGMENT Signature(s) _-Of._E.1mex...Johriaon and......... STATE OF WISCONSIN Marian-..7ohnsc n ss. ahenticat ------------- - Gci us 0-_da y ef..---_---5Iu-n .....` 2� _8 7 n.. ,.. . H Z H ' 9 STC - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d OWNER/BUYER �411fn �06VA15 ROUTE/BOX NUMBER 9001--r- Qso� ( /y A Fire Number CITY/STATE d4olmow) ZIP 574 00 2 PROPERTY LOCATION : 5L 14, `E Section 3 , T-28 N , R W, Town of �ca5'N Q,wt R , St . Croix County , Subdivision C5°e77 , 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 . I 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 I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth , herein , as set by the Wisconsin Depart- d ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Offic within 30 days of the three year expiration date . 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 . Timm JOB SHEET NO. Z OF Z Excavating Co. CALCULATED BY `� '�`— DATE R 1, Box 192, Wilson, WI 54027 CHECKED BY DATE • - SCALE .._. ......... 3M -rope X7 .._ al,e TDft_. dGG G✓S �fP.w� l�5 lrewhel mj�v /GYM� I I P4ZL = �' a 7 /57 Q1 T ........ .... 85 pole _ a vy Acl 40A k) 0a /vt Mss.01471 Timm JOB Adc-eN f�we.s SHEET NO. T OF Z Excavating Co. CALCULATED BY // -- DATE 7 Ao R I, Box 1921 Wilson, Wl 6 027 CHECKED BY SCALE j ........... ..., .. ... ... .... ... ._. .__. .._. .. ... .... . .. .......... .., ............ .. .......... d_. .r� 1 -b LL ........ _... .......... w:..........6 �s. ... . .. 4 90,2 b � ` : INSTRUCTIONS FOR COMPLETING FORM 115- S6[D - 6395 To be a complete and accurate soil test,your report must include. 1. Complete legal description; 3. The use section must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedrooms or cominercial 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; 0. PLEASE rise the abbreviations shown here for writing profile descriptions and completing the plot plan; 7- MAKE A LEGIBLE diagrarn accurately locati=tg your test locations. Drawing to scale is preferred. A separate sheer may k,e used if desired; S. Make srrre your benchmark and veitic.al elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate Foxes as to dates, names,addresses,flood plain data,percolation test exemp- tion, it appropriate; 10. If the information (such as flood plain,elevation) does riot apply, place N.A.in the appropriate box; 11. Sign the form anti place your current address and your certification number; 12. Make legible copies and distribute as rec uirtad. ALL SOIL TESTS MUST FEE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separates and Textures Other Symbols st Stone (ovol "10") BR - Bedrock co, .._ Cobble (3- 10") SS Sandstone gr __ Gravel (under 3") LS Lirnestorae �s - Sand NGW - High Groundlivater cs Coarse Sand Perc, - Percolation Rate med s .-- Medium Sand \'N - lratr,II fs ._ Fiat= Sarad Bldg Building Is Loamy Sane= -- Greater Than �Fl Sandy Learn < Less Than 'I __ Laan, Bn - Broar,n *sil - Silt Loarn Bl Black Sill Gy - Gray ci - Clay Loans Y - yellotiN' sci - Sandy Clay Loam R Reef sicl - Silty Clay Loam ntot - Mottles sc - Sandy Clay v v",itIr sic - Silty Clary fIt fevv, line=faint *r, - Clay cc; -- eornn'torl; f�'oarse pt - Peat orrn Many, mudion-1 m - (buck d - distinct p - prominent [AWL - Nigh rraater level, Six general sod textures surface water for liquid waste disposal BM Bench Mark VRP - Vertical Reference Point TO THE MINER: This soil test report is the first stela ira sneering a sanitary perrnit. The county or the Department may request vc€;fication or tl'is soil test in the field prior to permit issuance. A complete set of plans for the private soya urge. system and a permit application must be sulrrnitted tc, the appropnate local authovity in order, to obtrikl a pol vnit. The sanitary pariah must. be obtain"wd and I'o s).ed pl"ior to till shirt of aray constj,ncti(.)n. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INQUSTRI�, DIVISION LABOR AND 115)PERCOLATION TESTS P.O. BOX HU�VIAN'FiELATIONS 63.09(1) &Ch er 145.045) � MADISON,WI 533707 707 L(O1C� TION:: SECTION: p Nt£t LOT NO.:BLK.NO.]SUBDIVISION NAME: J E '�/�E'/4 3 /T._-8N/R i1(or)W Na- COUNTY: OWNER'S BUYPR/I'S NAME: MAILING ADD E55: CY01'S �(_VYI¢.tr �OV1r150K A35�1 - '/..^ hd¢ .�'S c77'� USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTION7ERCOLATION TESTS: Residence ®New El Replace F RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDING TANK.RECOMMENDED SYSTEM:(optional) Os ❑U ❑S QU ©s ❑U ❑� DU ❑S DU 3- 30 If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the rr under s.H63.09(5)(b),indicate: PIMP, Floodplain,indicate Floodplain elevation: r`0' PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 0•60 SiGT RFs �gn oa-os B- 7.0 9a.7 ti's s,� 32s- X83 r a.�d_�carn,r )215-3.OS B- 1 io.9� n�:�. r,)a �. 7S /.�S- 5 1; s.P/3o8-'f•7s 8.� �,ad s.c�S.s-L.4� 94.4 �O �; .0 '3-•93 13t3.0 .X.o-3•o W tL ARma- y.o 6.r7 -- 83-2.0_ r_��__�� 3.0-�4.Qglk S F;mo-r -5. As B- $.l0 1 x'10,js 0-9.2 BC 9 1 Fs.42_a.a5 8nel'" cob, ass-`•33 -ors c s coligel se 1.83-3.r1 8.si ` *n- f.43 dk Ff sf B- 9'7�5 "" ?,11-14,4x 15m m' b4..04 AA-b-•s•1 o �s/ cob Y �, B- 94�0 4 y 0-.15- 81 sL fs 7.33-.?6, B seL, ���- sc� �.c.��►�,I, 5o J 0 SI .7�-2 Ti-.33 B�st�� .30- 5.17 L—da-17 _914.1 5 N'a .5 - -7s 51,06.-7 S-.sdS o �n�s�e ZzLL ? ,0 O-. I S +S. _-8 B-_ S rEuSL l St.�.Qr 1. /s. 1Cr PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- .® NO r't t/ , P- 30 P- 2 o -7 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 the direction and percent of land slope. SYSTEM ELEVATION 01 , f . . }} vfzr 1 T 5 du 9e3 79 140 ttS_ 1 ro►r Jv Ih Y`el•d {OYpGL•; E E� ' ltl ] I T­ 7,__.. _ ___ _ t__._ I r i { � 17— � �� �° P Ela •45. t I I € 1 __.._ I 1 1 — � 4 j alk 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): / TESTS WERE COMPLETED ON: .-j �/—/3- F7 ADDRESS: f CERTIFICATION NUMBER: PHONE NUMBER(optional): f CST GNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. HR-SBD-6395 (R.02/82) -OVER -