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HomeMy WebLinkAbout030-1025-95-025 / ° \ m \ 2 � _ \ x B f * 0 ( ) • � \ f I § 2 » ) z k LL ) m . / L < _ . � . i § I z — } $ c § 7 a 2 E � 0 z \ \ & § E ƒ . k / (D b \ D k j z 0 ` E \ { / _ ) 0 CL 'm & ) a b ) } / k k k k 6 � I ) � •� \ a a a « I E U) -i \ \ ƒ I 2 § ) \ § \ C/) = = E w ILI � � (n a) LM 2 ; g % ■ » n o e o ; . § \ kk ® ® o © » 7 S I @ 8 o § / f / ) D k 7 \ / . k § j k / $ o c m ! _ = o z _ e s m ■ � 2 $ § a ) $ k a ; I � & J � � � � � o , � . . 1 l i I v 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,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: /&K `)� Trench: A C`ry� 2 Width: / Lenith Number of Lines: . :�i Area Built:0V Fill depth to top of pipe: yc '� Number of feet from nearest property line: Front, Side, O Rear, It Number of feet, f,° ,well: ` �e . _ Number of feet from building: Lg (Include distances on plot plan). SEEPAGE PIT N� 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 `'/4 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: from Number of feet f m nearest road: Alarm Manufacturer: Inspector: ::22zo A&./- l� Dated: / /�/ 7 Plumber on job: ki License Number: 25 12— 3/84:mj Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Ua)&,A 7 gu.SCT TOWNSHIP _Jus�/d� SEC. _(�o T 7 N-R /7 W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT -- LOT SIZE I!� acme PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM No L.Oe l 1)(4 C 1 r C plc ti hpu L o 7 / 'F ADO 6 / A VL It j___) f INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: &2k,_4a) J� ` �SLiquid Capacity: Number of rings used: e)O w Tank manhole cover elevation: rlts. d'E�4'T i Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side o Rear. Q 1996' t feet . From nearest property line : Front 10 Side,0 Rear, /06 feet LceA sate p , Number of feet from: well 4 04 , building: / (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE DEPA tMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING r4ADISOr*,W 1 53707 l7;d&, SE14,S6,T29N—R19W OCONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: ff assigned) Town of St. Joseph ❑Holding Tank ❑ In-Ground Pressure ❑Mound Pine Ridge Road NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Edward Hauser Route 2, Box 172, Hudson, WI 54016 0—e) J BENCH MARK WOrmanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: John P. Sykora III 3212 St. Croix 99107 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER I p PROVIDED: PROVIDED: i (p� �8,qq �8,l�0 ISYES ONO DYES SNO BEDDING: VENT DIA.: VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: I VENT TO FRESH �I- d ALARM FEET FROM LINE: /�' AIR INLET: DYES C9NO � ❑YES ANO 1NEAREST-----*tIOC r- IDo ' lL DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. JPUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: -]YES 1:1 DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER'.OF PROPERTY WELL. BUILDING:I VENT TO FRESH (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 MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LENGTH JNO.OF DISTR.PIPE SPACING. COVER JINSIDE DIA.. #PITS LIQUID BE0j.TRENCH` TRENCHES I MATERIAL: PIT DEPTH DIMENSICiNS � -42 IU GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO. TR NCIIMIBER'.OF PROPERTY WEL',L�-1 BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COV ER. ELEV.INLET ELEV.END: PIPES LINE: �YIJUI AIR INLET: r� FEET FROM L00 4- �,°.SAD 9 a �( NEAREST---�-1� tJt l07'I.t, 31 - t MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. 1:1 YES El NO SOIL COVER ITEXTURE PERMANENT MARKERS: OBSERVATION WELLS. 1:1 YES ONO 1:1 YES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =01 TOPSOIL. SODDED SEEDED. MULCHED. CENTER EDGES. 1:1 YES ONO 1:1 YES ONO 1:1 YES 0 N PRESSURIZED DISTRIBUTION SYSTEM: -I"D TI,ENCH TRENCFFES:WIDTH. LENGTH: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. E?IMENSIflNS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.. ELEV.. DIA.. ELEV.: PIPES: DIA.: ELEVATION AN -DISTRIBUTION. HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION ! PLANS: DYES ED NO ❑YES El COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LRNE ERTY WELL: BUILDING: FEET DYES ONO El YES 1:1 NO NEAREST > 14 6 L�.31 ,.,,0 IL. 2 Sketch System on c unty file for audit. Reverse Side. SIGNATURE: TITLE: Zoning Administrator DILHR SBD 6710 (R.01/82) INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT r r 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,..Wsuallyevery 2 to 3'�rears; 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: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; 11. 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; Ili. 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'Y2 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.grou,ndwater bill Ground aIter - included the creation of surcharges (fees) for a number of regulated practices which Wisco in'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried feaStlre is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank puriper_ 0 Pie monies collected through these surcharges are credited to the groundwater fund adminis- ter ec' by `he Department of Natural Resources. These funus are used for monitoring ground- t way e,, groundwater contamination investigations and establishment of standards Groundwater, s worth protecting. SBD-6398(8.03!36) SANITARY PERMIT APPLICATION COUNTY =; I LHRR In accord with ILHR 83.05,Wis.Adm.Code �. STAT ANITARY PERMIT## q/v y —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 81/2 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 © NO PROPERTY OWNER PROPERTY LOCATION a,," 41. /vW11, %:%, S (p TZCj , N, Riq E (o W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 2 LAM !7 CITY,STATE ZIP CODE PHONE NUMBER 7n CITY EAREST R E OR LANDMARK IS ,' O VILLAGE : c I�QICQ(A II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family `�`" OR ❑ Public(Specify):NA III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. X 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. tKConventional 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. AQ seepage Bed b. ❑seepage Trench c. ❑ See a e 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): eo r 6 Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons 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 Holding Tank /200 Lift Pump Tank/Siphon Chamber ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on ttLe attached plans. Plumber's Name(Print): PI ber's Signature:(No Stamps) MPQWff SW N .: Business Phone Number: 3Zl (715' 68-1-4'f? Plumber's Addressatreet,City,State,Zip Cod ; Name of Designer: ' - VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## ­1 3 Z"1 CST's ADDRESS(Street,Cit fate,Zi Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater N,/ Issu' g Agent Signature(No Stamps) S charge Fee Approved ❑ Owner Given Initial / �� X3� _ p '7W O Adverse Determination Q 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/contractgr, ("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 W 6L V d 5 Location of Property !)w k- 55�- Ix, Section T N - R W Township T U 5 112 Mailing Address 4 o u /, J 2-- Subdivision Name ILI Lot Number y J�'e Previous ejj��o Property 4 he S c �t f �^ S d Acir d y 1'41V A & Q c� w17-t, �/T 1 L_ Total Size of Parcel 3 Date Parcel was CreatedN''c y - Are all corners and lot lines identifiable? _ Yes No Is this property being developed for/reesale (spec house) ? Yes _ No Volume and Page Number �` (�as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed/// 2. Land Contract 3. • Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (fate-) eeAti.6 y that aU dza tementd on .this 6onm aae tkue to the bed.t o 6 my (oun) know.tedge; that I (we) am (ane) the owneA(d) o6 the phopeh ty des cAi.bed in fih,iA in6onmati.on 6oAm, by vchtue o6 a wamanty d ed neconded in the 066ice o6 the County RegiAten o6 Ueedd aA Document No. Y3 9 U /2 ; and that I (we) puAently own the p.4opo4ed e.a to bon the sewage poe ayd.tem WE 1 (we) have obtained an eaAement, to Aun with the above de cAi.bed pnopen ty, bon the const4ucti.on o6 aatd byd.tem, and the Game had been duty tecokded in the 066tee o6 the County RegiA ten o6 Ueedd, ab Document No. ) . SIGN TURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED 1 1 T 41 &34, a for 4`VAN"co"idered" fo11wt1K I��IMi>a�t NItaM'ii At ,� +�[�Coq�tf.stM�of ti�taNis ,.:North 12 rods Of the East 56 rods aAd tbs d_3 miss df tt Worth 5S rods of the East Of U;.`Vwthwest Quarter of the fvutheast _ of t y 29 *OtA. 'Range 19 vest:. �µy PL fill JO Y," �� �" .�,4`'�"FL•a"�,; .P��� f �} —rte �Et�,.� � #_ i 5 ; ,d �v 4� „ . a ~ K ' . 2 �3 . H z H 9 ST C - 105 r r H SEPTIC TANK MAINTENANCE AGREEMENT Ho St . Croix County z d n a OWNER/BUYER I WW W 4 ROUTE/BOX NUMBER 2c�t,( T� Z /�J`¢l�t Fire Number CITY/STATE HL4 C(f) ZIP S�10 16 PROPERTY LOCATION : AAA-1k, J k, Section T '2 ( N, R W, Town of S l— �`J�f St . Croix County , Subdivision Lot number/t4-1-A- 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. 0 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- ry ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office with n 30 days of the three year expiration date . SIGNED DATE /?1e1V 2,2- l/ u 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 . r • i INSTRUCTIONS IONS FOR COMPLETING FORM 115 - SBD - 6395 V To be a cornplete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a�wsidenee or commercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; S. Complete the Suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OU_f BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions an(] completing the plot plan; � 7, MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A separate sheet mavbe used if desired; £f. Make;surcx ycnur benchmark and vertical elevation reference point are clearly shown,and are permanent; f}_ Cornrkme all apt anon} late boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion.if appropriate; 10, l; the information n (such as flood plain,elevation)does riot apply, place H.A. in the appropriate box; 11, Sign the form and place ydui' current address and your certification nuhiber; 12, legible, cops ens and distribute as recfuiro,-I. ALL SOIL TESTS MUST BE F=ILED WITH THE ")CAL ALIT H0 ?TY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols s — Sro e €ov<a" 10"? FAR Bedrock r,oIn - o lh'u 10") Stanc3stearta, Grav(d , ei 3' LS L welston - s HGVV — Hiclh Gi,) readvvater f ciar.. .rrf Pcrc P ?mlcr r1. Rlit a J _. Sandy t_cmrn L arTa Bra — R,o,,-i Si 11, G t €'i F 10'a m :,,enn v i ay LiTT P2 � �uta y f:Eay 1w C _ , ,.ue .ri.?ity, HVt€L — l it L� e i, .-`r? Six '.�ofl ex Xt{o--'s a a isposai f`,=I'4''' __- 3er'.ch P"/ll';9"k VRP ....._ Witicad i +'if nr- poi-t T TIME OWNER: sn r St rof,o-t is ,K li st S:e p to sr,cursr q a sanitary pen mit, The county m the Department may request (:=E' [f=[.: 3€7€! the it 3rd {')k"ior io Po r1'$,is ;SSU.I lt'';, A €�T;3r"€ir')., ei of {hills for the private i rld a ne,r8t o Pain,, iC.a!t ,1`1 mwst rw star bitted to the Tf>}pf' pr?iite ideal ;,utiiorify in order to rrt,n tr'4., ,s iYiT#I( 1:-w Sa P€:a,rq'.l;':-s'r1"3it r"tic€;;t ''afa Ci f)'.c3itt€?„1 ',,-d Po Ted L:§4io, Lo tr ,sr,?rt of"In GC7ElstruGti€�r1, i INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS ' INDUSTRY, DIVISION 76,LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS II (H .09(1)& Chapter 745.045) LOCATION: SECTION: TOWNJUJ&AFUNICI PALI Y: LOT NO.:BLK.NO.: SUBDIVISION NAME: w 1/40/ jr4 ZT?.IN/R/?E ( , COUNTY: ` O ER' UYER'S NAM -7*INS ADDRESS: JUJJJJ u , USE y DATES 68SERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTI N: PROFILE DESCRIPTIONS: �O A ON TESTS: Residence N )kNew El Replace RATING:S=Site suitable for system U=Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) /�X OUl S ❑� S ❑� S ❑� ❑S �� EIS NU J .,y 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 t BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COL R,TEXTURE,'AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- / 77'2" / a� , , B-� /D� 9��//H h�+►e >_ t0�9 �k-zz�`iB�si 7s Z��-5�2'��s��-��= /�0� //Q 96'`z// 1"id�� //� v'=8 , 8N mW s $r 20"1.s11 r to t4/a'1$o B-'� //0 77'r haµ y I/b au 8" W s.. l Ts/ �`=�8'�'R'ts /t$i-ri0.04 B-6" /D$ .0d 0k� av- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER16b PER INCH P- / 0 e- 2L P- /r __Z P- /r me P__ 2 d /� 0 Y �• 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. d1i�Ds SYSTEM ELEVATION y r_... 42 tH goo I I 3 1, _ .. _ _._ .. ► C� _ r _ .._._ ? � po 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: (; g Z 9 97 ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional): Z B a !7-T 2!X 7 /S- -A46 C N AT DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS SAFETY & BUILDINGS DIVISION - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, ITI 53707 y ti •A APPLICATION FOR THE USE OF AN ALTERNATIVE SY EM Location: "'ownship/Municip lity: 1/4 1/4 Sect n T N R E(or)W Street Address: Subdivision• County: Landowners Name: Mailing ddress: I (We) , the undersigned, ma a application f r an alternative system on the above- described premises. If appr al is grant , I agree to have the system installed in conformance with the Bureau's pproval of plans and specifications. I further understand that an alt nati a system is more complex in nature than a conventional private sewage syste an as such will require detailed inspection during construction and monitoring after t system is put into use. I agree to permit both county officials charged with admin tering county sanitary ordinances and Bureau employes or other authorized perso s o have access to the above described premises at any reasonable time for the purpo a of nspecting the construction of or monitoring of the system. I further agree to ither rsonally or by my agent contact the proper county official to arrange the ime and to to begin construction of the system. I understand that this applic ion does not permit me (the applicant) or my agent (the contractor) to begin install ion. If the stem is approved, the Bureau will send the applicant a letter of approv 1 which authori s construction of the alternative system after all necessary permits have been obtaine . I agree to give notice to ny subsequent buyer hat an application for an alternative system has been made and f installed, that the remises are served by an alternative system and further agree o give the buyer a cop of this application. The Bureau accepts this application subject to th s understanding and subject to all the conditions and obligati ns set out in this applica ion. Signature f Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me this COUNTY OF date: Notary Public, State of Wisconsin I SBD-6413(R.08/85) My Commission Expires: w I lk ✓ S` f r � S n F c� l LP ell ; rn oe fb S � e . o y � r , � IRS m R 7. N A a� /�YHf/Oyu le This instrument drnk�_) No. 90-38 ELI 4'71.'735 > UNELAIIED LANDS �. t'1 G► Bearings are referenced to the C, SO396.001 east-west 1/4 line of Section 6, 1 Z 3 .00 LQI 1 C,SjL jL assumed to bear S8905212211W ftj rr n I� YQL� Zt M = W 0 H, QQ yr ° NO z0 - rr OD sy a 00 o 1 ° (SO000512711E) ° N N S000 1 1 1 1 211E " Z � �' 247.501 = .1. r ro N rn C " - C �.y 0 n O O CO (n CD F 7 C LJ N o NEB of the SW} L7 1° L12 ° = s z °- NWT of the SE} o �' N � �° o pn M - o 0 1-C ff fD I a � .•• c 1 r 0 (n I r• N G. 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