Loading...
HomeMy WebLinkAbout038-1105-90-000 . . . _ _ . . / y wN 2 § � f j 2 o \ 0 2 � § � � � . \ � . ■ ; ¢ � . � 2 � ? } � 2 7 2 3 \ � K J � § n 2 � / § § I z' z / : c w (L co w z I ! E ) § / ] \ I k k 7 / E \ I . @ m -� CO ƒ § Q } ) k j .. ) CD { 0 � � A k k ca CL d § k � - k CL CL 6 a a a z # « IL ' ) 2 ] 0 23 § § 2 \ k k 0 a k � © = E � § \ � 2 \ J ƒ J ) % ; ° § _ / � $ $ E 04 CS . � 4) = o o § K ƒ ) §\ \ § § 2 § 2 ) : E — 0 2 ] / Q 1-1© : \ _ $ I CO - \ \ \ . } k o 2 ) k k 2 \ 2 � . � , . @ C 2 U CL C E e ; = i k j a 0 2 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: Trench: Width: /, Length: Number of Lines: Area Built:-y � Fill depth to top of pipe: Number of feet from nearest property line: Front,/ O Side, Rear,O Ft .2j Number of feet from well: 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,,0 Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: �s � 7 Plumber on job: e License Number: IS 3/84:mj J Form - ST C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER , TOWNSHIP SEC. T fLN-R ZZ W ADDRESS ST. CROIX COUNTY, WISCONSIN s yore SUBDIVISION LOT LOT SIZE PLAN VIEW I Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ®Wry AP } 3l ` j INDICATE NORTH ARROW , f o BENCHMARK: Describe the vertical reference point used o Elevation of vertical reference point: �d p T/�� � Proposed slope at site: -�:�-- SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: �_ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,(\A Side,Q Rear, ��� feet From nearest property line Front,0 Side, Rear, 8 O feet Number of feet from: well (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.,%OX 7969. BUREAU OF PLUMBING MADISON,WI 53707 `� NE�,NW%,S26,T31N-4, 14ICONVENTIONAL 1:1 ALTERNATIVE State PllannI.D.Number: t Town of Star Prairie El Holding Tank ❑ In-Ground Pressure ❑Mound I If NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Mike McNamara Route 2, Box 34, New Richmond, WI 54017 (,- o 'al 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 95981 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL ILOCKING COVER PROVIDED: PROVIDED: OYES ❑NO ❑YES ❑NO BEDDING: I VENT DIA.. VENT MATL: HIGH TER UMBEfi©F ROAD: PROPERTY WELL: BUILDING:IVIER NT TO FRESH ALARM. FEET FROM LINE: INLET: DYES ❑NO ❑Y OR NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LI D CAP IT PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO 1:1 YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF :PROPERTY WELL. BUILDING: 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 the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: ,, WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA.. #PITS- LIQUID �w TRENCHES. / / MATERIAL' T—P—IT DEPTH. (� Jl GRAVEL DEPTH FILL DEPTH DISTR.P E DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER ELEV.INLET E V.END. PIPES: LINE: AIg,Iry LET. Z7 2 9 2 FEBTFROM 31 I I G $G plat J 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- meets the criteria for medium sand. TIONS MEASURED. DYES El NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO :1 YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED: MULCHED. CENTER. EDGES. ❑YES ❑NO DYES ❑NO DYES 11 No PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER TRENCHES: : MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: yy�I ELEV.. ELEV.. DIA.- ELEV.: PIPES. DIA.: till" ;HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED �FRn PLANS DYES ❑NO OYES El NO COMMENTS. PERMANENT MARKERS: OBSERVATION WELLS: NUMBER C3F PROPERTY WELL: BUILDING: FEETFR LINE: I I L1 Yes ❑NO DYES El NO MEATS r � Sketch System on o 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: 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 Iioensed 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; Il. 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 per-mit 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; Vl. 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 8Y2 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 In e caq effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reap fi is used in your building is returned to the groundwater through your soil absorption U ,!, 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- " t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) {� ,_._SANITARY PERMIT APPLICATION COUNTY u f'LHR In accord with ILHR 83.05,Wis.Adm.Code y STAT ANITA Y IIER91T# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8'h x 11 inches in size. —See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWNER PROPERTY LOCATION '/a '/a, T , N, R L (or) PRO ERTY OWNER'S MAILIN ADDRESS LOT NU BER BLOCK UMBER SUBDIV ION NAME CIT ,STAT , ZIP CODE PHONE NUMB VILLAGE: NEAREST ROAD LAKE OR LANDMARK A 24 II. TYPE OF BUILDING OR USE SERVED: / — r (0 Number of Bedrooms if 1 or 2 Family 5 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.X 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. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. 19 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): _0e 9-A Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons 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 Holdina Tank ❑ I El Lift Pump Tank/Siphon Chamber ❑ FELF ❑ ❑ I ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumbber's ame(Print): Plumber r o Stamp MP/MPRSW No.: Business Phone Number: m umb is Address(S eet,City, te,Zip Code): U Name of Designer: VIII. SOIL TEST INFORMATION Certi'ed S it Tester(C )Name CST# r C 's DDRESS(Str et,City, t e,Zip Code) Phone Number: T IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee Groundwater ate Issuing A ent Signature(No Stamps) Approved ❑ Owner Given Initial Su harg2e—Fee Adverse Determination a ' � X. COMMENTS/REASONS FOR DISAPPROVAL: blee 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 • J Location of Property 114, Section-, T N-R W Township Mailing Address Address of Site ,o0r_ Subdivision Name Lot Number Previous Owner of Property r,k& Total Size of Parcel q Date Parcel was Created / 7� Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume ate, and Page Number, _ 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) eeAti,6y that att s.tatemewta on xhia 6ohm aAe xnue to the but o6 my (our) knowledge; that I (we) am (ahe) the owner(b) o6 the phopen ty dens cA i.bed in xhiA in6onmation 6oim, by vi) tue o6 a wahAawty deed neeonded in the 066.iee o6 the County Reg.i.b.ten o 6 Deeds as Document No. ; and that 1 (we) pnez entty own the pnopoeed .6 to bon the sewage di,bpoe d y� em (on I (we) have obtained an easement, to nun with the above deaeh,'bed pnopehty, bon the eon tAucti.on o6 said eyb.tem, and the .same has been duty neeonded in the 066ice o6 the County Regi,6.ten o6 Veeda, ae Voecnnen t No. ) . SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DAiE SIGNED DATE SIGNED DOCUMENT NO, STATE I'M OF WISCONSIN-FORM Z ` �; �, :, r`« ' ." 1 s lJ ` rt » 3 1 L °" ' �s'; III1gi1�N?Y.bEEC► O 001tDINA DATA yDI11fE �+� s srk ,,J +,•s rr' K. s y� r , l o _.fvq.1H#Jt•t!Kd�p �,� s��� _ B'Y�'122y A ft yC 1�sll�t rk�rRS',0F��P1C�' Cd., 1 ls. .., ,. < Ia �. r r vii, ,� 3H �` a •. x Aid"Odr 96dord this ,Zkd Mi"oh�ieti_J. .MoNamar's and Karen B. tl�y Of., dim _A:b.19. 7 tae Nbnt+a0 ate tt+sMotb io t,. husband s�uld'wife•:; .A+� • Y� , Rsgfster of e a =� Grant a for i vilusble coeoldof atfo»' RETURN TO "TV*'hundred grid:no%100 'dollars the followift described real 0a,tate in St•-CTOix County,State of Wisconsin A parcel of fiend'Sri"th+ Northeast quarter of Northwest Tax Key r quarter .(Nh NW >of.Section 26, TownshiP 31 North This is homestead pro}ietty,•` Range 18 West" irt St.'Croix County, Wisconsin described as followst Commending at the Northwest corner of• Northeast quarter of Northwest quarter of j said Section 26,-.thence East for 660 feet to Place of Beginning, thence South from center of town road for 250 feet; thence East for 190 feet; thence North for 250 feet .to center of town road; thence West 190 feet to Place of Beginning. ..Containing 1.09 acres MNSF s- FEE Exception to warranties:, Executed at Nww Ai nhninnd, Wi annnci in thin day of Jung SIGNED AND SEALED IN'PRESENCE OF (SEAL)-' -- - (SEAL) Joe Francois _� ��6Z;n.r irf '(SEAL) 7` Genevieve Francois Lorene Johnson (SEAL) Signatures of_Joe Fr n _oig And Qpno.Viaye Fr nnnin, husband and VJ fe authenticated this day of , 19 I J_e__ W"!'- W, W A-R 1) Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 viz. STATE OF WISCONSIN as. County. Personally_,came before ma;this - day of , 19_, the above named - tome known to be the person.:, who executed the foregoing instrument and acknowledged the same. This instrument was drafted by Notary Public County,Wis. s i The use of witnesses is optional. r My Commission(Expires)(Is) Names of persons signing in any capeeity.should be typed or printed below their signatures. OOA►NIC •HINTING CO.. ■AU CLAII19.WIG. WARRANTY DBRD_"ATZ BAR OF WMONBIN. FORM NO.2 — 1071 K cn • y ,j a STC - 105 r SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z OWNER/BUYER ii ROUTE/BOX NUMBER�,,� 2X z �,/ Fire Number SSA $ 4 CITY/STATE /YEcf _ZIP 5 012 3S - i PROPERTY LOCATION: Section , T 3 N , R _W, Town of _S7fiA, PEA St . Croix County, Subdivision Lot number-� —• ' 1 Improper use and maintenance of your septic system could suit in its premature failure to handle wastes . Proper maintena�i_ con- sists of pumping out the septic tank every three years o ;#�o i ' oner , ?";< if needed, by a licensed septic tank pumper. What you 0'dt:- into :A 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 pro rF*im in August of 1980, with the requirement that owners of all ne ' ,stems agr&* to keep their systems properly maintained. The property owner agrees to submit to St ." Croix County Zoning a certification form, signed by t 'ie 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. o E I/WE, the undersigned, have read the above requirements and agree (n to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 10 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 . p ! ' SIGNED9, /)fZ —7 f ,I DATE I St . Croix County Zoning Office P.O. Box 98• Hammond, WI 54015 r 715-796-2239 or 715-425-8363 Sign, date and return to above address . INSTRUCTIONS FOR OMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report must include; 1. Complete legal description; 2, The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms oi-commercial use planned; 4, is this a new or replacement systern; 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; Pi. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A separate sheet may b e used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Con-iplete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp- tion,if appropriate; 10. If t.he informal lot') (such as flood plain, elevation)does not apply, place N.A.in the appropriate box; 11. ',Sign the farm and place your current address and your certification number; 12. Make I€,gible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY VVITLIIN 30 GAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separatcs and Textures Other Symbols s - Stone (over 10") BR - Bedrock cola -- Cohl-Ile (3- 10") SS - Sandstone cgr - Caravel (under3„) LS -- Limestone s - Sand FiG High G3"OUndwater. cs - C"czars€: S,a1)d Perk - Porcolation Rate rned s - Mediurra Sztnri Is Hill, Sand E;Iri g 13rr€idrng Is Loa'rny Sane! - Greaten Thall sl Sandy Loam C i_ess Than i Loam B ... Brovvrl "si! ._ Silt Lo<rra BI _ Blank Si Silt G ..._ Cray cl - Clay Loam y ... ye, Sandy Clay Loam R .._ is d sicl Silty Clay Loam rnot IMot0ea e - San(Iy Clay zrv/ t'°ith siC, - Silty Clay fff - fe~vv,fine,faint c ..._. Clay Cc --- C0111111Can,C>OWSCI r„ Peat rnm __ Many, r,edium ,r (ruck d - distinct p - Prominent HVVL - High water fevel, Six yoneral soil textures surface;water for liquid dispersal 8M - Bench Mark VRP - Vertical Reference Point- TO THE OWNER: This wait test report is the first step in securing a sanitary permit. The county orthe Department may request verification of this soil test in the field prior to permit. issuance_ A complete set of plans for the private sevvage systein and a permit application must be submitted to the appropriate local authority in order to oblain a permit. The .sanitary permit must be obtained and posted prior to the start of any construction. DEPARTMENT 6'F � ' REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LA50R AND, PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1)&Chapter 145.045) LOCATION: SECTION: N/� L (o TOWN SHIP/MU Y: OT NO.:BLK. : SUBDIVI ION NAME: 1 r C NTY: OWNER'S/BUYER'S AME: MA LI G ADDRESS: i USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL ESCRIPTION: PROFILEDESCRIPTIONS: PERCOLATION TESTS: Residence �� ❑New Replace. I RATING:S=Site suitable for system U=Site unsuitable for system (y� CONVENTIONAL: MOUND: ROUND-PRESSURE:SYSTE -IN-FILL OLDI G TANK:RECO ENDED SYSTE :(op nal) 14.1 S ❑U SDU SDU ❑S ( JU IS U If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH M, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) > C7 B- B- B- 3 B- B- PERCOLATION TESTS a , KUTVIIER DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES INGI4ES AFTERSWELLING INTERVAL-MIN. P RIOD PER 2 P PER INCH 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 plar�Shp Atha surface elevation at all borings nd the direction and percent of land slope. �T ct/ l• �� �Q ��a �� /G`- SYSTEM ELEVATION # # i 4, , 3 It 11 _ t I I N i I i — j { i fdll i I a T 1 I sj 7 E -� - I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures an methods specified in th Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. ;U-7-7")7 NAME rint : TESTS WERE COMPLETED ON: • - - R 7 AD SS: CERTTIFICATION NUMBER: PHONE NUMBER(optional): GNATURE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR SBD-6395 (R.02/82) —OVER — i • /�/J'J//,J� /]////f 7 Ate/ ` �� /� �� ` T �� ��¢�J 3a 3 5s -Asa 7 AS t � PAGE OF Crc) SS Szc ' lon o � a j6ic Systt°�� �r�� /"L!{✓i�A7,� /¢ Fresh Air Inlels And ObNI'VOIIOn PIPS C�)_Approved Vent Cap / Mlnimnwn i2"Move �rinal Grod• , 20-42"Above Pipe —4"Cast Iron To Final Grade Vent Plpe Hersh Fay Or Synthetic Covering mein. 2"Aggregate Over Pipe Oletrlbullon —Too Pipe 6"Aggregot: o PotuateG Plpe Bslcw Beneath PIP a —Coupling Terminating At Bolton Of System r �l e,.�•. ton \��������� SOIL FILL DISTRIBUT101.1 PIPE APPRJVED SlINTHETIC COVER ""-MATERIN, OR 9" OF STRAW 2"OFA6GRE4AlF. -� /yam R MARSH NAy ° (o OF%2-2m/2 AGGREGATE ELEV. oF.i F¢AT--.. DIS'T'1115UT10k) PIPE TO BE AT LEAST I►JCHES BELOW ORIGIMAL GRADE AWU AT LEAST20 INCHES BUT kI0 MORE THAI) 42 IAICNES BELOW FIAIAL GRADE MAXIMUM D61"N OF EXCAVATIOWI FROM ORIGINAL 6KAoF- WILL BE IMCHES MINIMUM MT-0 of EACAVATIOM RoM-o*lGlaqL (aRAPE WILL BE It�ICHES SIGAIEO: LICEMSE IJUMBER: DATE: �.l