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HomeMy WebLinkAbout040-1094-30-000 -0 °o e p °v> ry O 0.� O C� O O N N N I is II h i a z C LL C 'L7 @ O N Q (O I. I M m z rn c w ' z N y y 00 a m 'T CN N f Z O O Z zt C U U O O 0 a) Z d c N H S O O z c E 'o -O N M N (D N n V i C •� ) N Cl) O L) O N Q U z co z i5 N z N E N 7 O a° co tS R c i a N N c CD ° N c CL E N N N !, fn (n N O m uV—. FL = o t�ryy � 000 z •rte a a a o w r- n w L) rn rn M L w S o in n E N N m m rn U) 6 aNi ';> O U N N M y C I N M j O N O(O CO O O O O (7 M C ? O O O O NN ON N O OO FO- I'.. V) C N N C • 7y„i a O T N Z Z M M U N a) 7 0 m I- £ O O V 7 O N U O 04 0) () r v � E N �r 7 ik a j d CL .�`. • c� m .� d a Parcel #: 040-1094-30-000 02/22/2007 01:03 PM PAGE 1 OF 1 Alt. Parcel M 24.28.19.381A 040-TOWN OF TROY Current X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O- INLOW, STEVEN A&JODY A STEVEN A&JODY A INLOW 233 CTY RD U RIVER FALLS WI 54022 Districts: SC= School SP=Special Property Address(es): '=Primary Type Dist# Description "233 CTY RD U SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 6.200 Plat: N/A-NOT AVAILABLE SEC 24 T28N R1 9W NW SE EXC P381 C&EXC Block/Condo Bldg: NORTH 981.75 FT Tract(s): (Sec-Twn-Rng 401/4 1601/4) 24-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 11/09/2005 811655 2925/336 EZ-U 07/23/1997 763/188 2007 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/20/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.200 79,000 205,200 284,200 NO i Totals for 2007: General Property 6.200 79,000 205,200 284,200 Woodland 0.000 0 0 Totals for 2006: General Property 6.200 79,000 205,200 284,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 313 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 r PUMP CHAMBER ` Manufacturer: Liquid Capac t : Pump Model: Pump phon MaiufAa Pump Size Elevation of inlet: B tom ion: Pump off switch elevation: le: Alarm Manufacturer: pe: Number of feet from near stprop y l ineSide, O Rear,0 Ft. Number of feet from well. Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: �s Trench: Width: JZ Length: Q slumber of Lines: , Area Built: �l�D Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,O Ft .541 Number of feet from well: Number of feet from building: ,2 3Jr (Include distances on plot plan). SEEPAGE PIT Size: Number yBotom ts: ! Di ter: Liquid depth: of s epage pit le tion: Area Built: Has either a drop box O or d tri ution ox O bee u ed o any of the above soil absorbtion sytems? (Check one HOLDING TANK Manufacturer: Capac y: Number of rings used: Elevation o b t m of tank: Elevation of inlet: Number of feet from nNfeetrom line: nt, O Side, O Rear, OFt. Numbm well. Number oildin Number of fee road. Alarm Manufacturer: Inspector: Dated: —210—f / Plumber on job: �. License Number: 3/84:mj Form - S T C - 104 * * AS BUILT SANITARY SYSTEM REPORT OWNER .S'cv� d TOWNSHIP V SEC. Z7` T �d N-R W ADDRESS /VO ST. CROIX COUNTY, WISCONSIN SUBDIVISION / r� LOT A l LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM e. /Taut� 90 �- /000 �d Gc�ees a� I I R �z 190 X —4--, 0 4-- - J ---INDICATE NORTH ARROW B.m, G cfy �d BENCHMARK: Describe the vertical reference point used 7,510 a 74ACL 693" on Elevation of vertical reference point: /DO.O Proposed slope at site: �' o SEPTIC TANK: Manufacturer: Liquid Capacity: load Number of rings used: z k� Tank manhole cover elevation: Tank Inlet Elevation: / ,S9 Tank Outlet Elevation: /J,2. 70/ Number of feet from nearest- Road: Front,O Side ,O Rear, ©,54D_�" feet From nearest- property. line Front to Side,M Rear,O /��/ feet Number of feet from: well 90 , building: (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE 1 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS .LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PL P .O.BOX 7969 UMBING MADISON WI 53707 /'� N2, SEA, S24,T28N-R19W EXCONVENTIONAL ❑ALTERNATIVE State Plan 1.D.Number: (lf assigned) Town of Troy ❑Holding Tank ❑In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA E: Steve Inlow 315 4th Street North Hudson WI 54016 w'� 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: Dale E. Hudson I6629 St. Croix 92534 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER N1) PROVIDED: PROVIDED. IW ��a,?4 �J� ,�t'� ®YES El NO ❑YES 'KNO BEDDING: VENT DIA.: VENT MATL.: NIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING:IVENTTOFRESH ALARM: J'�/'� LINE. AIR INLET: FEET El YES ENO C1-_ ❑YES ®NO INEAREST-----)l O M 'nn I DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL- JOUILDING JVENTTOFFEESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑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 JINSIDE CIA *PITS LIQUID BED/TRENCH � Q TRENCHES f MATERIAL: PIT DEPTH DIMENSIONS i C, V 0 �- RAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO. ISTR. NUMBER OF PROPERTY WELL BUILDING: V NT TO FRESH BELOW PIPES. ABOVE COVER: ELEV.INLET ELEV E D PIPES LINE. AIR INLET a ^ FEET FROM � O� laD,4� C9 NEAREST---► 54 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. ❑YES NO OIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS 1-1 YES 1-1 NO ❑YES 1-1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER: EDGES. OYES ❑NO 1:1 YES ONO ❑YES El NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD Of PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIALS,MARKING ELEVATION AND ELEV.. ELEV: DIA.. ELEV.: PIPES 1.A. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS F-1 YES NO I 1:1 YES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE s DYES 0 N El YES 1:1 NQ NEAREST �JA) ��as Ll �a Sketch System on Retain in county file for audit. 3 7 t� Reverse Side. TUpRE: TITLE. - DILHR SBD 6710(R.01/82) ' �!b'n�uo C Zoning Administratc 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: 1. Property owners 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 o 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, certificatior number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when appli ation is disapproved. Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scalE or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) hor zontal 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 chang in statutes was the result of over 2 years of steady negotiation and public debate. ThE. groundwater bill Ground *qr included the creation of surcharges (tees) for a number of regula ed practices which Wiscorf, irf,S can effect groundwater. The surcharge: took effect on July 1, 1984 All of the water that buried �rea UI•B is used in your building is returned to the groundwater through y ur soil absorption o 1 system or the disposal site used by your holding tank pumper. a The nnonies coilecte3 through these surcharges are credited tot the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- 1 water, groundwater contamination investigations and establishment of standards Groundwati-r, it's worth protecting. SBD-6398(R.03/86) SANITARY PERMIT APPLICATION COUNTY KLIn ac ord with ILHR 83.05,Wis.Adm.Code ' 'I Z � �..o. 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 ® NO PROPERTY OWNER PROPERTY LOCATION S� ✓c N 4' % $E %, S 2-e/ T2,0, N, R / 0(or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 3 � - S . /v/V /V/� /V CHIT/Y,STATE ZIP CODE / PHONE NUMBER *7�/ CITY NEAREST ROAD,LAKE OR LANDMARK TOWN OF �s0/I S7O/lv /� .! (O�7/7 VILLAGE: /Y O ��''11 G��I. 11. TYPE OF BUILDING OR USE SERVED: X.4' d 4yo - `O?d Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): A l 111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. � New b. ❑ Replacement c. El 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 onl v one in#2) 1. a.Z 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: (Chet one) 1. a. X seepage Bed b. ❑See a e Trench c. ❑ Seepage 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): n_Q 7 J`� 7v X 32 Feet Private ❑Joint El 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 Holding Tank /0O0 /000 Z,2e, ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ 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 Stamps) MP/MPRSW No.: Business Phone Number: -Dale s; s n XI& n d&,"Z9 7/-,!5' 337 Plumber's Address(Street,City,State,Zip Code): Name of Designer: Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# ///� male E, u�so 3_ CST's ADDRESS(Street,City,State,Zip Code) Phone Number: Sox l I-W d & r-O lal -'-te o Z IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial � S rcharge Fee Adverse Determination loo.cw ,U0 X. CO,M1MENTS/REA NS 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 i 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 -c Location of Property Section , T N - R A? W Township Mailing Address Subdivision Name Al Lot Number , Previous Owner of Property /�ij'fa '11-16 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 7�. and Page Number If? as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. arranty 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 (We) avLa6y that att d.tatementA on .thiA 6oiun ahe t4ue to the bed# o6 my (oun) know.tedge; that I (we) am (are) the owner(d) o6 the pnopen ty ded eh i.bed in .th i.e in6onmati.on 6o4m, by viAtue o6 a wahAanty deed neeonded in the 066ice o6 the County Reg.i,d.ten o6 Deedd ad Document No. �03'1/7 ; and that 1 (we) plied entty own the pnopod ed d.cte 6 oh the d ewage di,6posat d yd.tem (on I (we) have obtained an eabement, to kiln .with the above dedeh.i.bed pnopen.ty, bon the condtkuetti.on o6 chid dyd.tem, and the dame had been duty )Leco&ded in the 066ice o6 the County Reg.cd.ta o6 Deedd, ad Document No. ) . r SIGNATURE OF OWNER SIGNATURE F CO WNER (IF APPLICABLE) /2921. T.z9 "7 . DATE SI ED DATE SIGNED NINk fiTAlfgR . r tow 10. Q� %"/PAct . Milton D. Hovde TM DEED,made between sw ' Cuanta �C f _ busband- 8:30 A nn surylyin dip marital_n�nQrty Grantee, x W i t a e s t a e s s e t h. That the said Grantor, for a valuable consideration ---- at-T 10 0 h Wesci(6ed real estate in r h County. State of Wisc-nsin: part of the SEk of Section 94-28-19 descrif' ' ."-follows Beginning at a point on the North/South � .a t line of said Section 24 a distance of 1592.80 feet ax Key No. No rd► from the South k corner of said Section 24 (said � . beginning point being 35.00 feet South of the South line of the Riot feet of said Southeast k of Section 24) ; thence N89°36040" E 563x.04 thence SO4 012'45" W 180.30 feet; thence S02 058' 15"W 212.26 feet : SZ7 048'05"E 334.80 feet; thence S29 017'20"E 713.00 feettOth45"� " 44 .214.60 feet; thence N47°15'50"E 108.82 feet; 1 thence N37 3220 W445.75 feet; thence N76°13'05"E 436.52 feat:• 33'45" E 252.72 feet; thence S87°58'25"E 511.38 feet; 420.41 feet; ther._e N87 27' 00"E 485.57 feet; thence N13°02"3 Fes,~ thence N27°54' 15"W 93.76 feet to the South line of the North, said Southeast k; thence S 89 036140" W a distance of 2220.66-r . South line of said Section 24; thence S00°00'00"E (assnoe„ said North/South k line a distance of 35.00 feet to the A ' +, a. This_____—is -no ----t homestead property , -- Ril�i0619X Together with all and singular the hereditaments and appurtenances thereunto belongivVI,� And warrants that the title is good, indefeasible in fee simple and flee and clear of encumbrant , reservations and restrictions of record; and will warrant and defend the same. TEL . day of December 3 Dated this (SEAL) (SEAL) AUTHENTICATION ACKHOMLED � Signatures authenticated this_----"—dal►o f STATE OF WISCONSIN ---. t9_— PIERCE�_ _ C09011 Y.4 " Personally came before due,this'+, December, 198.ki abotne TITLE: MEMBER STATE BAR OF WISCONSIN _ --Milton D (if not. --- -- -- - authorized by '1706.06. Wis. Stets.) -- - --- This instrument was drafted by Charles E. White, Attorney at Law ton Drs rumen a the eck , l3 River Balls, Wisconsin 54922 (Signst area may btq authenttcafed or.acknowledged; Both \ o ., 1 are not necessaU.l wt is My'C issi. y date �.:.. •Naeaes of perdons'p�ttn�r► u� ant rptacity @tv�t be iyesd ur printed be their aittrtatu'i{,. rsreruu T Vitttn srt tt orr w►uroxstty, poreri kO t-ivr; v . z cn H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a OWNER/BUYER S)Ieye_ ROUTE/BOX NUMBER _315' �,r �f, /C4, , Fire Number .CITY/STATE ZIP PROPERTY LOCATION: Z , -'5'_'E 14, Section `1! , T ` F N, R 19 W, Town of _2el:�O v , St . Croix County, Subdivision AVA , 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. H 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- Fc 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 — � � Q�/ DATE g 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 . 1319PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, BOX 7969 O LABOR AND PERCOLATION TESTS (115) MADISON WI 30 HUMAN RELATIONS (H63.090)&Chapter 145.045) LOCATION:S SECTION: u R TOWNSHIP/MUNICIPALITY: LOT NO.:BLK_NO.: SUBDIVISION NAME: y E�/ ! /Tz8"/"/9P(or 0 COUNTY: OWNER'S BUYER'S NAME: MAI ING ADDRESS: USE DATES OBSERVATION9 MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: =FlReplace PROFILE NS: A I N TESTS: r,WResidence ♦/ New RATING:S=Site suitable for system U=Site unsuitable for system rMS ONVENTI NAL: MOUND: IN-GROUND-PRESSURE:S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:( ptional) ❑u ❑s Mu as [2u as ®u os ®u If Percolation Tests are NOT required DESIGN RATE:: /J If any portion of the tested area is in the under s.H63.09(5)(b),indicate: N /✓/�' I Floodplain indicate Floodplain elevation: s PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTHIM. ELEVATION OBSERVED EST.HFG-HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) i �� �� 41 B- .33 /03.7 . /(lon 7,53 B/s,' . 52 ' .�y� ° s B- Z x•75' 100109 ItAo02 e > 7S� / /�� s,l "',«ns B-3 -Z 1XRZ /f le,,V Zf 61'2 s //, 0 7/ L B- 4 77.D /oo�� �o�� > '7,off'� /� 19�1�r. ' 33 �BrJS B- PERCOLATION TESTS TEST DEPTH!, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER lfefe*E9 AFTERSWELLING INTERVAL-MIN. PERIOD)L= PERT D2 PER PER INCH P- N 8 / 8 P-Z e— o rA' P- A49,i e, d ' 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 9�'�-3Z ._ .--- .. LL i i _.._4. I— _ - � i --- N1 i ! j ! 1 ' � I I 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: a e .�. ,�✓u -20 -F7 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): _?4e13 171-1 ti'-;3601 CST SIGNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. 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