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HomeMy WebLinkAbout032-1064-50-000 M Q cfl a a 0 ts m o ` N aai a CD ca cn 3 tt Ov I CD S m I C U yv CD C N CD —0. Z m 7 N U. c M E I mn m E ¢ w i U I M CL r � H rn w E Z -- °o E D z �, d Nevi I o. m I o I cc o z v c y z o a I m F- �' CD E a E C0 N c N 0 ca a> 1� co N N N Q1 •N 42 U) = O I 0 o a�i Q z m z N z c I df N A E I .. co 2 a 'R o c m N Lo d m CO I o 0 o a E ^� n = 3000 z R I a (D U E 0 co � E rn rn o N z AV CD N co zi� N p Q N rl- co O Q ml y c d i O d ja O O W co r N co 0 CD F4 I 0) . c c a 00 °O I O 4) ! v �n ra 1�1 M E t6 O Y O O E L O N fn ', a' O z 2 H �' In r� ca V a � *� •� � a I ,� ea c 'm d m �1 A ciao 0U) 0 PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size , Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Length: �a/ Number of Lines: �° Area Built: Fill depth to top of ,pipe: p? / Number of feet from nearest property line: Front, O Side, 0j Rear,0 Pt . )J:5 Number of feet from well: 1 55-G Number of feet from building: �S O (Include distances on plot plan). l / SEEPAGE PIT ��� �e T n 1612_ Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated• �� 7 ,7 Plumber on job: License Number: 3/84:mj Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER e2 rcl TOWNSHIP '50 19.7r5z SEC. T�N-R �' W ADDRESS gOX ) ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE ``-- PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 � q .1� SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Weil &"7 c, 6 s o7a.5' 5i sr i lb 13y INDICATE NORTH ARROW r L BENCHMARK: Describe the vertical reference point used /��A-, 6 Elevation of vertical reference point: IC70> Proposed slope at site: f , SEPTIC TANK: Manufacturer: 7`3 Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: .�"� Tank Outlet Elevation: _�67</ - ' Number of feet from nearest Road: Front,�Side 0 Rear, O o? D feet From nearest property line Front,0 Side,O Rear,O 1�c2 If feet Number of feet from: well /2e? , building: 13&- / (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 P.O.BOX 7969 BUREAU OF PLUMBING All DISON• WI 53707 4, S24,T31N-R19W nCONVENTIONAL 1:1 ALTERNATIVE State Plan I.D.Number Town of N. Somerset ❑Holding Tank ❑ In-Ground Pressure ❑Mound (H assigned) 205th Avenue NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Louis Rivard Route 1, Box 120J, Somerset, WI 54025 I'5" ?- �.8,7 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REP.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No. County: Sanitary Permit Number: Byron Bird Jr. 3318 St. Croix 96065 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER (� ^ P O ICED: PROVIDED. S5 5w �j � • Lil YES ONO ❑YES �NO BEDDING: VENT DIA.: VENT MATL.. HIGH WATER UMBER OF ROAD: PROP(R WELL: BUILDING. VENT TO FRESH A LARM. FEET FROM LIN : Z LAIR INLET ❑YES NO C ) ❑YES NO N (7 U J U ' u DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY. 1I`11MP MODEL_ JPUMP/IIIHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: EYES —]NO ❑YES ❑NO OYES ❑NO GALLONS PER CYCLE: PUM P AND CONTROLS OPERATIONAL. NUMBER OF '.PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) EYES ONO NEAREST,` SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH D AND MARKING or excavation, (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) I MAIN' CONVENTIONAL SYSTEM: WIDTH: LENGTH N .PIPE SPACING: COVER INSIDE DIA. #PITS HEII��INT LIQUIBEq/TRENCH TRMAT RIF I,IT DEPTH. is GRAVEL DEPTH FILL DEPTH I PIPE MATERIAL: NO.DISTR NUMBER OF PROPERTY WELL: TO FRESH BELOW PIPES. ABOVE COVER. ELEV.INLET ELEV.END PIPES LINE R INLET: FEET FROM dot I 67. w w �r � 72� NEAREST I3s sV S�7' 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 ONO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONO OYES 1:1 NO DEPTH OVER TRENCT DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER EDGES. DYES ONO DYES 1:1 NO IEYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: BE®fTREfUCM WIDTH: LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING -E I LEV AT 10 N AND . ELEV.: ELEV.. DIA.: ELEV.. PIPES. DIA.: I�STRfBtJTION ' HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED IRIFCfR(>�4T�N PLANS: ❑YES El NO OYES —]NO I C NTS; PERMANENT MARKERS: OBS ERV,ANION WELL NUMBER OF PROPERTY WELL. BUILDING: �'-T� FEET FROM LINE: J l OYES 1:1 NO ElYYES 1:1 NO INFEARE ST Sketch System on a in in county file for audit. Reverse Side. SIGN �. TITLE: Zoning Administrator DILHR SBD 6710(R.01/82) 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'h 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 Groundtef---- included the creation of surcharges (fees) for a number of regulated practices which Wisco it 'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reAsur a 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 pumper. 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- f water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) SANITARY PER IT APPLICATION COU���G✓�CJ ew � QLHR In accord with ILHR 83.05,Wis.Adm.Code STAT SANITARYPERMIT# OWN -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 applicatio 1. PETITION 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMAI ION. FOR VARIANCE ❑YES 0 NO PROPERTY OWNER DIROPERTY LOCATION p/, ( C'/a 1&%, S AV T , N, R /f E (or PROPERTY OWNER'S MAILING ADDRESS OT NUMBER BLOCK NUMBER SUBDIVISION NAME oZO J-- o CITY,STATE ZIP CODE PHONE NUMBER CITY , �t A EST ROAD AKE`OR LANDMARK '`�L ca-S .--� VILLAGE: D tr`S�/ 7/` 4/ee 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR rPublic(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2 3 or 4,if applicable) 1. a. r New b.XReplacement c. El Replacement of d.❑ Reconnection of e.❑ Repair of an System System Y stem Se tic Tan 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 cond tions meet minimum requirements. 4. ❑ The System is shared by more than one owner/buildhig. Attach Common Ownership Agreement to County.Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. a. XConventional 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. ISeepage Bed b. ❑seepage Trench c. E See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSOR 3TION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSE (Square Feet): L 3 o 4ls � 6•/0 Feet Dd Private ❑Joint El Public VI. TANK CAPACITY f Site in aa ons Total #of Prefab. Fiber- Exper. INFORMATION Ma ufacturer's Name Con- Steel Plastic New xisting Gallons Tanks Concrete Tanks Tanks strutted glass App. Septic Tank or Holdin Tank �� � El 1-1 ❑ ❑E ❑ Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamp ) MP/MPRSW No.: Business Phone Number: e! ron i e r ail 7�S ?6 Plumb 's Address(Street,City,State,Zip Code): Name of Designer: oX terL c.,- Lt1 t 5 o rc� r VIII. SOIL TEST INFORMATION Certified S it Tester(CST)Name CST# 4eP 40 1.4 el 7 CST's AWRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Grou dwater ate Issuing Agent Signature(No Stamps) 14 Approved ❑ Owner Given Initial S rc arge Fee Adverse Determination ���'0O ,� v� X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,I ne Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY PERMIT S T C - 10 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 appr priate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - / Owner of Property 6 C,t S `�` ! I�� I �/ R ar00 Location of Prop ty SL— h; rVC h;, Section Z q T 31 N-RL W Township Jc�s__4 Nailing Address 6 ,, �v2 0 X a22_2Q.A_.,_0 I GJ szs Address of Site Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (s ec house) ? Yes _�_ No Volume I and Page Number as recorded with the Register of Deeds. 7 ^-0 v3 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 dertified 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION I (Wel ceAti.6y that att s.tatement6 on zhiz �o ahe hue to the best o6 my (ouh) hnowtedge; that I (we) am (ahe) the owneA(s o the pnopenty dmcAi.bed in .thiA inAonma.tion 6oAm, by viAtue 06 a waAAanty deed neconded in the 066ice o6 the Count Reg.us.ten o6 Deeds as Document No. x{23 and that I (We) p4uentty own -the pnoposed bite 6oh the sewage diApos ys em (on I (we) have obtained an easement, to nun with the above deb ch i.bed pnop y, 6oh the con tAuc ti.on 06 said dyd.tem, and the came has been duty kecokded in the 066.tce 06 the County Reg•i.e.ten o6 Veede, aA Vocamen t No. I . n ,11 SIGNATURE Op OWNER r SIGNATURE OF CO-OWNER (IF APPLICABLE) &7 21- 11 IIGNED DATE SIGNED , H • z H ST C - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT St . Croix County z tv OWNER/BUYER ,�[�CQ l S 9` �O/l� V ROUTE/BOX NU BER 60 l�� Fire Number CITY/STATE ZIP SOS PROPERTY LOCATION : 14, Section , T T 31 N, R W, Town of TY1?pi� 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. 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- v 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 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 . it II i DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982� THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 423073 BOOK 771 PAGE 79 I - - - - - _ iECASTERS OFFICE his e@ made between Gerald W Miller and Anna Ci ------ ST. CROIX CO., WIS. E . Mil er, us an an wife, d this 6th ------------------------------------------------- ---------------- ---------------------------------------------- ROCV- for Record ----------•----------------------------------------------------------------------------------------- --- -- ----------------- ---- Grantor, )dy�of Marcch A.D. 1987 Louis - : "1�ivardT�---a-"sirigTe mari; i and -------------------------------------------------------------- ---- 8:30 A ----------------------------------------------•--------------------------------- --------------- ---------------- --------- -------------------------------Grant atplce of Ooo/e -- ------------------------------------ -------------_-------------- of n W1tng SSe th, That the said ranto , for.a valuable cons'derati n,_____ Dollars and other good and varluable cons ic�erarion, S--. CrOiX RETURN TO conveys to Grantee the following described real estate in __________________________________ � County, State of Wisconsin: �j Tax Parcel No: ----------------------------------- ' The East One-half of the Southwest Quarter of the Northeast Quarter i (El of SW! of NE4) and the Southeast Quarter of the Northeast Quarter (SE4 of NE4) , EXCEPT the East 466 . 8 feet of the So-ath 466 . 8 feet thereof, ii all in Section 24 , T31N R19W . j !I This deed is given in satisfaction of a land contract between the it parties dated May 15 , 1984 and recorded May 17 , 1984 in Volume 688 of records at page 212 in the office of the St . Croix County Register of Deeds . $ 300.60 i FEE' i i ' This ___is not -------------____--- homestead property. (11;) (is not) Together with all and sin u the here itaments and a u t nances there nto belonging; g Gerald W . Miller and Anna E . 'mer , husband and wife , And • ----- -- ------ ------------•- - --- ---- ---- --- --- - --- - --- - - -- - --- ---------• ----• •- ------- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except subject to existing highways and subject to easements and restrictions I„ of record and will warrant and defend the same. i Dated this ------ - � November ------------ 19---86-. day of ------------------ ---------------------------------------------------------------------(SEAL) ----------(SEAL) * --------------------- --------------------------- Gerald W . Miller --------------------------------------------------- -------•--------------------- ---------------------------------------(SEAL) ---- 51:._ ---.....(SEAL) l * ----------------------------------- ------ ------------------ * ------Anna--E-•---Mil_ler------- ------------------- '! AUTHENTICATION ACKNOWLEDGMENT Signature(s) ----------------•------------------------------------------- STATE OF WISCONSIN -------------------------------------------------------------------------------- Burnett ss. -------------------------------County. p��rl i authenticated this ________day of_________________________, 19------ Personally came before me this _11__._______day of November 19. 86_ the move named ------ Gerald W. Mi7Ter and P,nna . ii * Miller;-- hush aril grid wife j' ----------- ------------------------ ' TITLE: MEMBER STATE BAR OF WISCONSIN -----------------------------`,___-r�„„T_ ,'---------------------------------- (If not- -------------------- ------------------------------------ `�� authorized by § 706.06, Wis. Stats.) r to me known to be 44 p rmblf 18:------------ who executed the i I foregoi instru 1sr' _" o ledge the same. THIS INSTRUMENT WAS DRAFTED BY `, . . 4 I ___ _ 1_ _ J _____ -`t BENSON--- ND TAYLOR Attorne s at Law -- , - Box 370 Siren Wisconsin 54872 Notary Pubc�_ ____$ ie_ t__O_______Connty, Wis. --- - - ---------------• --------- - -- - - My Commission - - - - - - ------- (Signatures may be authenticated or acknowledged. Both �� .f not, state expiration j are not necessary.) date: ---------•-- ----------- .........-°•-----"-----.-, 19-�7) j *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1-1982 Milwaukee, W is. I 1 ` l ` INSTRUCTIONS FOR COMPLETING FORM 115 - SR - 5395 .. To be a complete and accurate soil t est,Your report must include: 1. Complete legal descriptions; 2. The use section must clearly indicate whether this is a residence of commercial project; 3. MAX IMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement:system; B. Co mplete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE use the abbreviations shown Caere for writing profile descriptions and completing the plot plan; T. 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 Mates, na€saes,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 for m 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") BIB Bedrock cob Cobble (3- 10") SS Sandstone gr — Caravel (under 3") LS — Limestone *s Sand HGW High Groundwater c:s Coarse Sand Perc — Percolation Rate med s - Medium Sand W -- Well fs — Fine Sand Bldg - Building Is Loamy Sand > — Greater Than �sl Sandy Loam < Less Than <I ._ Loam Bn --_ Brown s.1 Silt Loam BI — Black Si Silt Gy Cray �cl Clay Loam Y — Yellow scl - Sandy Clay Loam R — Red sicl - silty Clay Loans snot — Mottles sc Sanely Clay w,' vvi th sic, — Silty Clay fff few, fine., faint *c _..._ Clay CC -.- coaramon,cos€se P! Peat mm — Many, medium ill ._ Muck d — distinct p _ prominent I-IWL - High water level, Six general sail textures surface water- for liquid waste disposal BM — Bench Mark VRP Vertical (deference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit.The county or the Department may request verification of this soil test in the field prior 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 permit must be obtained and posted prior to the start of any construction. QEPARTMENT•OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY,. DIVISION DIVISION LABOR HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION:j� SECTION:�"� p� NSHI UNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: �4 `V4 /�/ H/rC E (or v�o e/' C COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: ,G,% �oKi Marc o /moo - JIo 7` o�- USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence *7 ❑Newieplace RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: I IN_ -GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) 1ZS ❑U YS ❑A I DdS ❑U ❑S ®U ❑S U 1 If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: © 1044- O PROFILE DESCRIPTIONS BORING TOTAL D PT O GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- l rf '�Y. ^a���i1 S a2s/- 36 10.1 � -*' 41 90-3s d� ��� gam_ B-3 B- B- B- ��� PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER1003 PER PER INCH P- • P- OZ P- P- 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 and the direction and percent of land slope. SYSTEM ELEVATION `�6 •/O 3 1' I`m E . t 3 / E I E w 1 -- . __ _. 9 ' � IN _ _ . .�' z 3 3 .ti t I _ _ m 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: ADDRESS: _ CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIGNATURE: i2gt?.� i DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. 15ILHR-SBD-6395(R. 10/83) —OVER — PLOT PLAN PROJECT /,OK 1'5 ADDRESS /,90SC /0zd J -5'01'ftef'5,e7( N/R /T W TOWN A, 5o ewa-1t0UNTY G rd;X MPRS Byron Bird Jr. 3318 DATE 7-l0 --0;7 � BEDROOM 0 CLASS PERC -�2- CONVENTIONAL IN-GRO D PRESSURE CONVENTIONAL LIFT MOUND_HO ING TANK SEPTIC TANK SIZE d-m LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE 16 Benchmark V.R.P. Assume Elevatio 100' Location of Benchmark �5�� ^ �� �- e� �� / 4S * H.R.P. /gym- 0 Borehole Well Scale = Feet 0 Perc Hole System Elevation TYPAR COVERING t 2' 12' 3- Q g- 0 3' 3' Q 31 6 Sewer Rock 18 12' Von,T ap,-I 1-7. IB �• 3/�,� fib' y I , �,y, f' 73 >5w