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HomeMy WebLinkAbout032-1054-20-000 § 0 � 2 � � # � t 2 � � 2 $ 2 z 0 LL C § 3 \ J 2 « i £ � iwl E � Z t § � § z � \ z t 2 E 7 © � \ 2 �f AA E CL ) f f \ ) 7 .. 7 .. E $ ƒ � q i- / f m o o n k ( - }k > IL a k k k � a a a 2 - q E § § z C o o \ _/ \ & 2 8 8 a G 3 k § § . § / E 2 q / _/ / k co ` � � k # \ ƒ w . 0. % § k a c , , c k g S ° Q Q / § 0@ e e u IL o 0 0 o o o J % � § c - Q Q Q Q Q e ) § $ @ ] @ £ ¥ # & 2 2 n , 2 \ E ` § 2 D 6 { k D \ 5 / { § § Q 3 ) § 0 2 p f / 2 / 2 � « k C 'Oki � 0 k CL § & L) a 2 0 2 J Parcel #: 032-1054-20-000 03/10/2015 02:12 PM PAGE 1 OF 1 Alt. Parcel M 21.31.19.2696 032-TOWN OF SOMERSET Current ❑X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date - Map# Sales Area Application# Permit# Permit Type #of Units 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner O-MANSFIELD, LARRY L&DOREEN K LARRY L&DOREEN K MANSFIELD 491 210TH AVE SOMERSET WI 54025 Property Address(es): •=Primary *491 210TH AVE Districts: SC=School SP=Special Type Dist# Description SC 5432 SCH DIST OF SOMERSET SP 1700 WITC Notes: Legal Description: Acres: 10.007 g p SEC 21 T31 R19W 10.007 AC E1/2 OF NE1/4 LOT 1 CSM VOL 6/1666 Parcel History: Date Doc# Vol/Page Type 07/23/1997 777/263 07/23/1997 745/220 07/23/1997 646/140 Plat: "=Primary Tract: (S-T-R 40%160'%GL) Block/Condo Bldg: * 1666-CSM 06-1666 032-86 21-31N-19W LOT 01 2015 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/12/2010 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 10.007 53,000 110,700 163,700 NO Totals for 2015: General Property 10.007 53,000 110,700 163,700 Woodland 0.000 0 0 Totals for 2014: General Property 10.007 53,000 110,700 163,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 502 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 PUMP CHAMBER L Manufacturer: Liquid Capacity: i 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: l Trench: Width: Length: Number of Lines:�_ Area Built: //S" Fill depth to top of pipe: ,�Q Number of feet from nearest property line: Front, O Side, ® Rear,O Ft 1� Number of feet from well: Y51 Number of feet from building: (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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: ��Aj �)yJ License Number: 3/84:mj Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNS / ,�L Al 'ir>///> TOWNSHIP SEC. ) T _N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN r SUBDIVISION �=54- 5 Z — LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM LSs- 0 L fi I' 29 198? L ZONING r OFFICE INDICATE NORTH ARROW BENC ARK:, . Describe the vertical reference point used , Elevation of vertical reference point: l� ,Q Proposed slope at site: 6 SEPTIC -T)&K: • 6anufacturer: - S �� �,� Liquid Capacity: f' / Number of rings used: Tank Ymanhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: ,Number of feet from nearest Roard: Front,®Side, Rear, O , feet From nearest property line Front,0 Side 10 Rear,0 feet �/� Number of feet from: well —./00 building: building: (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 MADISON;Wl 53707 P.O.BOX ,, BUREAU OF PLUMBING WI NE4, NEk.S21,T31N-R19W )W CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: (If assigned) Town of Somerset ❑Holding Tank ❑ In-Ground Pressure ❑Mound t NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Larry Mansfield Route 2, Star Prairie, WI 54026 '7_D3-9'7 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 95980 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER „- ^ I ,^" P OV DED: PROVIDED: (yvM1, /vTl`-r�v YES ❑NO ❑YES NO BEDDING: VENT DIA.: IVENTTL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: IVEN T FRESH \/\/� ALARM. FEET FROM LINE: AIR INLET: OYES ❑NO ❑YES E1 NO NEAREST DOSING CHAMBER: MANUFACTURER. RE 1NGS. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO OYES ONO EYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL ILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES 1:1 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: ygyr,�yx�/ ��yy ww��iiwwt,,Y WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE CIA. #PITS. LIQUID F14F..RdT' Tf4XAt TRENCHES- MATERIAL: PIT': DEPTH: GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR,PIPE DISTR.PIPE MATERIAL: NO-DISTR. Ni�MBER PROPERTY WELL: BUILDING: V NT TO FRESH 1 I BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END. PIPES MEET FROM LINE: AIR INLET: .NEAREST 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- ❑YES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER ITEXTURE PERMANENT MARKERS JOBSERVATION WELLS DYES ❑NO DYES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOI L. SODDED SEEDED. MULCHED. CENTER- EDGES. DYES 1:1 NO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: s ENt TRENCHES: ,?.MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV. ELEV.. DIA.. ELEV.: PIPES: DIA.: � t�T ANA :HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. OYES ONO El YES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL: BUILDING:Fio)M ° LINE: DYES El NO DYES 1:1 NO ��I1 � Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: 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, 608-266-3815. 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; 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 Ground Ater = , included the creation of surcharges (fees) for a number of regulated practices which Wisco in a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried rE'asur@' 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. a 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- water, groundwater contamination investigations and establishment of standards. Groundwater, t it's worth protecting. SBD-6398(R.03/86) DILHR SANITARY PERMIT APPLICATION COUN�` v In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY 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 �ZNO PROPERTY OWNER PR PERTY LOCATION N, R (or) PROP TY NER'S MAILING ADDRESS LOT NU BER BLOCK N MBER SUBD VI ION 7NME CITY,STAT ZIP CODE PHONE NUMBER 71 CITY NEAREST ROAD,LAKE OR LANDMARK ED VILLAGE : II. TYPE OF BUILDING OR USE SERVED: O3 'l0 Number of Bedrooms if 1 or 2 Family. OR n Public(Specify): A0 III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. N New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an t 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. Jdl 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. N seepage Bed b. ❑Seepage Trench c. ❑SeeDacle Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes p r inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet ❑Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xis Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks I Tanks strutted Septic Tank or Holding Tank ❑ F]__❑ ❑ Lift Pump Tank/Siphon Chamber Li I U ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of he p 'vate sewage system shown on the attached plans. PI fiber's Name(Pri PI is Signatu :(No S mps) MP/MPRSW No.: Business Phone Number: J��L Plumb is Address S eet,City, t ,Zip Code): Name of Designer: 1 } VIII. SOIL TEST INFORMATION Certifi , So" Tester( T)Name CST# CS 's DDRESS rest,City,S ate,Zip Code) Phone Number: J IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Stary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) GSAroved charge Fee pp ❑ Owner Given Initial py` `� Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: U't-e It'j Pcl SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 42S281 Vt. / 1PASS 2^3 REGISTERS OFFICE __.._ .-- ---__-•— -------_.__-- ST. CROIX CO:• WI& This Deed, made between .....Thomas W. Barton and Reed. for Reawd ft 5th --- ---------------------- Lynda_•M. Barton husband and wife, as joint day of M_ a_� A.06 198_Z ten Ats� _---•--- - - ---- - -- d 8:30 A -----•---- •---------•----•---•-----------------------•---••--- ............. ------------------, Grantor, and----Laxxy.,.I,,_._ fi.jd__anc__Dor� rl__IC.-.Marisfld_,_ hush xld---an-d- wife-,-------------------- - +r • ------------- •--•------•--•--- ........................... ----------- ---- Grantee, Witnesseth, That the said Grantor, for a valuable consideration_..._. - ----- --___---------- conveys to Grantee the following described real estate in _._St.....Cr01.x......... RETURN To I` County, State of Wisconsin: Tag Parcel No: ---•-----------------•------------- Part of the East one-half of the Northeast quarter (Eh of NE4) of Section Twenty-one (21) , Township Thirty-one (31) North, Range Nineteen (19) West, described as follows : Lot l of the Certified Survey Map filed on June 17, 1986, in Volume 6 of Certified Survey Maps on Page 1666 as Document No. 413405. r This Warranty Deed is given in satisfaction of that Land Contract between grantor and grantee dated June 26, 1986 , and recorded in the St. Croix County Register of Deeds office on June 30, 1986, in Volume 745 of Records on Page 220 as Document No. 413871. FEE This .......i•S_ 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 oxoeR4X and will warrant and defend the same. Datedthis - •------------.,�� .......>*-------- day of -------------------------------------------- 19---8.7.. n C)'............(SEAL . / f � •: -!�a, ........_(SEAL) _.._...ThPvi4,__W.__ Barton i ynda K. Barton ---------------------------------------------- ......................(SEAL) ---•-•-- .......(SEAL) * ..----•---.. ....................................... ............. AUTHENTICATION ACKNOW'LEDC4MENT Signature(s) ___--•------•---------------•...............................- STATE OF W)aMZXW 11INN SOTA ------- ------ ss. ....•• ..-• - •----County. authenticated this --------day of___________________________ 19._. Y ersonull came before me this .&-'�k.day of --------- ...............•----, 19__81. the above named i .....Thomas...W*...B.4r. on__and Lynda rI....... ....................................................... - ---------------- _..Barton_ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, `^rized by § 706.06, Wis. Stats.) .......-------------------- .................................................... to me known to be the person B......... who executed the foregoing in trumsame. ent and ackn led a the s g RUMENT WAS DRAFTED BY NORMAN_ & SCHUMACHER, S. C. !------••------ erita a Drive *•-_ _ `K tVANCY LCtOSBkOCK- _c-hm,ond-,---W1--•5.4.01-7-- --•--•--- Notar. Pubh ---------- ma be authenticated or acknowledged. Both o rmajWhr iw—"'Usoifiou iratiin ssa Y) g• My Commis �-' erma}y���,��J �/Na�� a piration date My commission expires Jan. 25, 1189 ---- ) 'sons signing in any capacity should be typed or printed below their signatures. i DEED ATATR tcwu n. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property v`r.,� s 1 -t ,�4 Location of Property 1l)r' ,1%, Section 6Z I , T _/ N-R /9 W Township S Mailing Address 2 . I o �r C,J1 S C Address of Site !?� Subdivision Name IV . Lot Number Previous Owner of Property i Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes _�_ No Volume / and Page Number /0.3 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) eehtt6y that ate 8tatementA on thiA 604m ane true to the beat o6 my (owe) know.tedge; that I (we) am (ate) the owner(d pen ty des u i.bed in thi d in6ofimafii,on 6oAm, by vi tue o6 a ww m deed teemde ,,i.n the 066ice o6 the County Regi4ten o6 Veed6 ad Voeument Na -S��LSad'f ; and that I (We) ptesentty own the proposed d.ite bon the sewage od d d (on I (we) have obtained an easement, to Itun with the above deachibed pro y, bon the eondtnucti.on o6 Aai.d system, and the same had been du.Cy recorded in the 066tce o6 the County RegiAten o6 Veeds, ad Voeament No. ) . SIGNA OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED z H 9 ST C - 105 r a SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County z d OWNER/BUYER L_Q rt-y@ ►nSi e �C� ROUTE/BOX NUMBER Fire Number t r _ CITY/STATE �l -• �`1"`'' ZIP t 9 PROPERTY LOCATION : ,&�_ , IUD section c;21 , T N , R W, Town of St . Croix County , Subdivision 414A 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 . Ho E 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- •u 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 . r SIeNED DATE t 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 . src�/ 41;4 AYI 1, A-a • � � � -Sore=,cs;�1' i � 1 ' PAGE OF c 1 CroS JZC ' lor, o � /� � rl� SySTr°n� Fresh Air Inlals And Observation Pipe ��—Approved Vent Cap . 11 Minimum 12"Above Final Grade 20-42°Above Pipe _4"Cast Iron To Final Grade Vent Pipe Marsh May Or Synthetic Coveting Yin. 2°Aggregate Over Pipe Distribution —Tee Pipe o 0 6B esib 1p o PerfarofeJ Pipe Gslay Beneetb Pape o —C:p Ing Terminating At bottom Of System �.1 e.v•.�- I to n ���\\�����i SOIL FILL DISTRIBUTIO0.1 PIPE APPROVED S4WPETIC COVER MATERIl�4 OR 9" OF STRAW Q"OFOGREWE -� ° �y ORMARSN HAy (e1 OF i2 -2i� AGGREGATE i ELEV. OF,Z�FEET 2 a° v D15r-RIF3UTI0N PIPE TO BE AT LEAST INCHES BELOW ORIGILIAL GRADE AAIU AT LEASTZ0 iUCHES BUT AIO MORE TRAM 42 INCHES BELOW FINAL GRADE MAXIMUM ®EPtH OF EXCAVATiawi FRoM ORI&WA.L 6KADF- WILL BE �1�7� INCHES MWIMUM grfrh OF EXCAVADOW fF,01-\.-04�I6INAL GRAPE WILL 6E INCHES SIGAIEO: -C L ICE M5E AJUMBER: '/x -� DATE '_ 1 1 0 ,t �lE•a CP,ATMENT OF REPORT ON SOIL BORINGS AND LXqO HUMAN AND PERCOLATION TESTS (115) MADIS HUI',AAN RELATIONS (H63.090)& Chapter 145.045) ,/ pQ ]�H y: OT NO.:BLK.NO.: SUBDIVISION NAME: 1 SE / „ F(or) N OW ER'S WI.$ G DATES OBSERVATI S MADE BEDR COMM CIAL DESCRI TIO p OF DESCRIPTIONS:R esidence LZNew El Replace RA?r Ss Sit*suitable for system U Site unsuitable for system T NAL: MOUND: IN-GROUND PRESSURE: STEM- N- LLHOLDIN ANK:R COMMENDE SY TE :(o onal) a ®s o 2s au os Ou as u If Rer,,olation Tests are N*T required red DESIGN RA'E: If any portion of the tested area is in the / urtders.H63,09(5)(b),indicate: sir Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS r I TOTAL ELEVATION DEPTH O GROUNDWATER-INCHES HARACTER OF S L WITH 1 KNE S, OR, TEXTURE,AN' DE Hi,. DEPTHS' S TO BEDROCK.IF OB RVED(SHE ABBRV.ON_BACKJ k ;F �• w. >: PERCOLATION TES r ER IN LE TEST ME DROP IN VV^TER A flSWE! ING INTERVAL-MIN. - R P IN Ri k r � r Show locations of percolation tests, soil'borings and the dimensions of suitable soil areas. Indic scale @r distances, Describe what aii�the vertical itevatlaiin reference points and show their loistion on the plot plan. Show the surface elev on at all borings and the direction,-said pa R M ILE VATION _ , _. _._..�._ . �__.,.. . _ -r I Y ILL K. / i i i I T// 1 j 1 ( ( t } I,the undersigned,hereby certify that the soil tests reported on this form were made by me irtaccordwith the proyedures and methods specified in the 10 isponsin Administrative Code,and that the data recorded and the location of the testtare correct to the hest of ray knowledoand belief. A t)` EST§ ER �COMPLRTED ON: CERTIFICA ON NUMBER: PHONE NUMBER(taptlonal): RE: 4 a y M I III iTil1l jolON:Original and one copy to Local Authority,Property Owner and Soil Tester. DiLHFi-$Q -6395 (R.02/82). OVER— • ,,.. ,.