Loading...
HomeMy WebLinkAbout040-1183-40-000 7` � \ C; w 2 _ \ ) (D & 0 m ) . / D e = � LO � R � } % � 2 D \ [ � 2 g % 02 ) 2 \ i j / § § 7 � § % m // a ■ . / Bkk_ 7 \ :!t §$ § ® \ 2 z D _ ® [ \ k E z ' in ' » ) Q zmz £ § � R « c / � § ) � \ C: a 4 0 o a % § / U) k a- z � § 2 2 2 -L; i _ E 2 v > \ 7 D "*Ala ' 2 \ ) � jam ƒ 2 � � 2 (D 2 2 ¥ m A a U) / k : C14 V) \ / 6 § (L C:, ( g / \ 0 ) @ ¥ % k \ ® § 2 ° f \ ~ § ' \ \ / , \ k o z \ j k \ � ® � � 0 ■ at k - \ - ) cc E a k a § / 3 a 0 3 L PIMP CHAMBER Manufacturer: Liquid Capacity: Vol * 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,Q 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: Fill depth to top of pipe: ;2 fi t, Number of feet from nearest property line: Front, Side, O Rear,O Ft . Ad Number of feet ;'rom well: I"rQ { 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• A Dated: Plumber on job: License Number: L S� 3/84:mj �i Form - STC - 104 4 AS BUILT SANITARY SYSTEM REPORT +r OWNER L! TOWNSHIP SEC. T--'P,?N-R ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION - LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i _ - -- 4 S, k JLJ IV 3 1 { f P s INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point usedd�/too 10 Elevation of vertical reference int: / oposed slope at site: StPTIC TANK: Manufacturer: j a..� e,►Axa Liquid Capacity: j,2 S^Lrj,car Number of rings used: Tank manhole cover elevation: 9�-s Tank Inlet Elevation: 23, 78 Tank Outlet Elevation: -3, S Number of feet from nearest Road: Front,O Side eear, 0 Q J feet From nearest property line - Front 10 Side,0 Rear,0 feet � Number of feet from: well 1-5 Q building: )9) p (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 yLA6 &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION r'.O. -47969 BUREAU OF PLUMBING MADIS N,WI 53707 SW-4, S36,T28N-R19W EXCONVENTIONAL El ALTERNATIVE State Plan l.D.Number: (If assigned) Town 1! Troy ❑Holding Tank ❑ In-Ground Pressure ❑Mound Lot 29 'Danate Park NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION AT r: Roger A. Swanson Route 5, Box 124, River Falls, WI 54022 _ _8 _ d 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: Henry Nechville 3258 St. Croix 99088 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER 1 1 _ PROVIDED: PROVIDED t5 . 1 �J ES ONO DYES ONO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: B VENT TO FRESH ALARM: FEET FROM �� LINE. \�Q AIR=NLET. ❑YES 54NO ❑YES �O INIAREST UD DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO ❑YES ❑NO ❑YES ONO 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) DYES ❑NO 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.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH: 11\0�01` DISTR.PIPE SPACING. COVER INSIDE DIA.. #PITS. LIQUID BED/TRENCH ^ /� TRNCHES �( M ERIAL: PIT DEPTH 011MENSIONS �iJ( U GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR,PIPE DISTR.PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPE ( AB COVER. ELEV.INLET ELEV.END PIPES LIN AIR INLET: FEET FROM Q q3t I1 �`� 27, .3 NEAREST ( 150 'b -40+ 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 SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS El YES 1:1 NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED. CENTER EDGES. 1:1 YES 1:1 NO 1:1 YES 0 N ❑ El NO PRESSURIZED DISTRIBUTION SYSTEM: / WIDTH: LENGTH. TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER D#MEIIQiNS :, MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.. ELEV.. DIA.. ELEV.: PIPES: DIA.: ELEVATION AND IRIBUTION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS: 1:1 YES ONO O C, DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSE ION S: NUMBER OF �[PL PROP LINE WELL: BUILDING: FEET FROM LI ❑YES ❑NO YES ❑NO (apAREST ' 0 Ll Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: � TITLE: ,., ZOT,A1 g Administrator DILHR SBD 6710 IR.01/82) INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION �' • r 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 licer.sed pumper whenever necessary,.usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator c r the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. 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'/2 x 11 inches must be submitted to the county. The plans must include the fallowing: 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 me result of over 2 years of steady negotiation and public debate. The groundwater bill arou,,i c;water -- included the creation of surcharges (fees) for a number of regulated practices which `Mscon,i is can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that vuried treasure is used in your building is returned tc the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. 0 The inomes collected through these surcharges are credited to the groundwater fund adr-inis- terec by the Department of Natural R,-,=sources. These funds are used for rnonitoring g our t � ater, gr )uridwater contamination in.estigations and establishment of standa-ds is worth protecting. BD-6398(R.03/86) ILHR SANITARY PERMIT APPLICATION COUN In accord with ILHR 83.05,Wis.Adm.Code S§rAW SANITARYYPERM►T# 60 d .Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 1 finches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPE TY OWNER PROPERTY LOCATION .- w 0./y Al S4J '/4//X '/4, S Sri T .� , N, R l E(o PROPERT WNER'S MAILI G ADDRESS LOT NUMBER BL MBER SUBDIVISION NAME CITY,STATE I ZIP CODE PHONE NUMBER LJ CITY NEAREST ROAD,LAKE OR LANDMARK �!A- -D( + 7-2 7ys �Y� -9/98 � OQf( 'e� 1c `taE 11. TYPE OF BUILDING OR USE SERVED: OHIO ' 7 j +00(0 Number of Bedrooms if 1 or 2 Family Ad OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. RoNew b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) L� 1. a. Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPT19J4 SYSTEM INFORMATION: (Check one) 1. a. RSeepage Bed b. ❑Seepage 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): s $ ?;2109 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 Holding Tank /%mod &Iwf AlIke LA-1 F_ 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 Stamps) MP PRSW No. Business Phone Number: x41,*k 111,i5cei l/ r 3 S /5 7yg-33� Plum er's Acrdress(Street,City,State,Zip Code)- Name of Designer: VIII. SOIL TEST INFORMATION IV Certified Soil Tester(CST)Narne CST# O J GS -m-,41 O�/ (O/t o(/ CST's ADDRESS(Street,City,State,Zip Code) Phone Number: Q S ��r IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps Approved ❑ Owner Given Initial kp /� S rcharge Fee``\\ Adverse Determination /� i Qv X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY PERMIT STC - 100 his application form is to be completed in. full and signed by the owner(s) of the roperty 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- W a, AK -S p Location of Property Q U) k /V if-:7 h;, Section 3w , 7_2a-N-R J 2 W Township Mailing Address Id 57 _11N Address of Site Subdivision Name q, A) 2, 2La Pat k k Lot Number 2 Previous Amer of Property Jf r- r D -} tiS& �' © Ot-A , z221 -a— Total Size of Parcel f 1-5--f /Acted- Date Parcel Man Created 246:t Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes Z--, No Volume end Page Number IS— 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) cent ti.6y that a.f t e.tatement6 on .this onm Me tltue to the beet o6 my (oun) hnowtedge; that I (we) am (ahe) -the ownerc(e� 06 the phopelety de cAi.bed in .tUA in6onma.Lton 6o4m, by viAtue o6 a waAAanty deed keco&ded in the 066ice o6 the Cocmty Re-gis.ten o6 Deeds ae Document No. ® �c . ; and that I (Ole) pneaentty aun .the pnopoaed h to bon .the -sewage di�spos eye em (ok I (we) have obtained an eaa ement, to stun with the above deb eh ibed pnopeh ty, bon the eon tAucti.on o6 said eya.tem, and the dame hae been duty keeokded in the 066ice 06 the County Reg,i.a.teA o6 Veedb, ae Doeantent No. ) SIGNATURE 01? OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED Form - S T C 100 Owner of Property er A --t- s4-Y'a (7� c� i1Sdn Location of Property p rty�j ' _� F ' Section 3/,T� N R _W Township__ 7--*y Mailing Address /Q s Sox /a?4 Subdivision Name Dana7e- farK Lot Number ad- Previous Owner of Property Yer#w^ 4k 6041 Total Size of Parcel ..S9 aereS Date Parcel Was Created_ I /&I I Are all corners identifiable? _ / Yes No r i Include with this application one of the following : . Certified Survey Map . Deed . Land Contract , or . Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge;that 1 (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty dead recorded in the Office of the County Register of Deeds as Document No. 562z177 ;and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system,and the some has been duly recorded in the Office of unty Register of Deeds,as Document No.4&V 27 7 ), SIONJURK OF OWNE p 51 N URE OF CO-OWNER A LICAOLE) a JAI 1J, I Qd� GATE S NED DATE jiGNED 2 'VOL 1 1Z)PAGE This Deed, made between -Vernon L. Rasmussen and AEGIVERS OFFICE Rax I& Carolyn A. husband and wife, and each___•__________ ST. C CO.,, �?i.thir own right, ----------------- - - ------------ i RK'd for s 25th Record Mai ---- --•• - - ------------------------------------ ----- -. Grantor, A.D. 1q 8 er A Swanson and �� day of_� 5 jand -- -------- ------------------------------------ t 1 :10 P k� Sall G. Swanson, husband and wife,•------------------------------ y as .joint_tenants------- ------ - --------- ------ --------- -- y of - ----------- Grantee, ` ; Witnesseth, That the said Grantor, for a valuable consideration....__ it i � y �O]x F RETURN TO conveys to Grantee the following described real estate in ...__r... ...._.-._- ( County, State of Wisconsin: i i E I Tax Parcel No: ................................... Lot Twenty-nine (29); Danate Park Subdivision,: TbM-i of Troy,. (subJect to: a11: restrictiV;e._eoVenants__of record) . —"a t, i I This is--not..-_____- homestead --------- property.. i, (is not) i Together with all and singular the hereditaments and appurtenances thereunto belonging; And..-Vernon L. Rasmussen and Carolyn A. lasmussen - ------ -------- --- ------------------------------------ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except for ease easements, restrictions and Restrictive Covenants of record, and will warrant and defend the same. Dated this --_--------------<0 -/-9------------ day of --------- June - 19.85 i (SEAL) (SEAL) „ Vernon L. Ra sen * er A. Swanson ------- - - --------------------------------- --------------- - -- -- - -- - -- --- -- ----- Fi--1�. 1r►. - .t----------(SEAL) AL) * Carolyn X. Rasmussen Sally . Swanson AUTHENTICATION ACKNOWLEDGMENT Signature(s) ------------------------------------------------------------ STATE OF WISCONSIN ss. •--•-•---•---------------•-•• St. Croix --------------•---•...------------..County. authenticated this ........day of___________________________ 19...... Personally came before me this ....19th....day of --------`7U1 -----------------•------P 19.85--- the above named Vernon L. Rasmussen ----------------------- *--------------- --------- ------------------------------ ------- --- ........Carolyn -- Rasmussen --------- -------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN Roder A. Swanson ---- •...................••---• ----------•---•••----------------- (If not, -----------_---------- -- - Sally G. Swanson ------------------------------------------ authorized by § 706.06, Wis. StatsJ to me known',to"C m.s er Rfr 8 who executed the ILhe. p is ......... foregoing irwtrtilAent-arid••&claA�-v(lgdge the same. THIS INSTRUMENT WAS DRAFTED BY ••• W.C. M.Bye, Attorney at Law .......... -� ,Q�i�1��--..----�- --� + ------------------------ — Di :L. *Mtake4 P. O. Box 167 *------- - --------- ---- ---- ,; --Ri.-ael^-�'a1.1$ -•�-- X4422•--•----------------•-------- --- Notary1 b1 ,�'= - - �'u �'_��.. _ _--___County, Wis. (Signatures may be authenticated or acknowledged. Both My Commfv;�1--is permal}enY�[i� not, state expiration are not necessary.) � date: ---.�.. , .. --��.---..................... 19.88...) *Names of persons signing in any capacity should be typed or printed below their signatures. Cam'dw STATE BAR OF WISCONSIN H.GMi1IerConpany� FORM No. 1-1992 Stock No. 13001 • H z N i y a STC - 105 r a y SEPTIC TANK MAINTENANCE AGREEMENT c St . Croix County x ty ((^^ a OWNER/BUYER r' �' Z?ro �. t" ROUTS/BOX NUMBER Q '�p ,fj y / Fire Number .CITY/STATE- Rayioz ZIP S4/'0,?,R PROPERTY LOCATION: SW 14, WE 4, Section Ap , T_me?fN , R_L? _W, Town of Troy . St . Croix County, Subdivision Inah"4 Park . 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 N to maintain the private sewage disposal system in accordance with x 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 Zonin Office within 30 days of the three year expiration date. SIGNED- 14, Z DATE IV 7 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. INDUS DEPARTMENT, , OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 ) HUMAN RELATIONS 1 / MADISON,WI 53707 (H63.090)&Chapter 145.045) LOCATION: SECTION: TOWNSHIP/AA OT NO.:BLK.NO.: SUMIVISION NAME: SW '/�P/ 36 /L29N/R/9E (o Tre T0"Ins-L aNTY: OW405er ER'S B YER'S AME: IMAILINGDR SS: cyc x R S gox /.4, Rover Falls ti✓,s tors.:, S-W 2 USE V DATES OBSERVATIONS MADE F5 NO.BEDRMS.: COMMERCIAL DESCRIPTION: I Residence U STS: 7 New ❑Replace �'u 9/ /7f7 J u/y 9 RATING:S-Site suitable for system U-Site unsuitable for system 7 J ♦i r UNVENTI NAL: MOUND: IN-GROUN : S S -IN-FILL OLDING 0:1 RECOMMENDED SYSTEM:(optional)®S CJU AS ❑U ®S ❑U Ills ConvewLi'ana e If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: / ~ 4 1 oN/g /�t fS / �. �� odplain,indicate Floodplain elevation: f h PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROU NDWATER-INCHES HARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH FN; ELEVATION OBSERVED EST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- //,DO /00,4y JI/on� 7 //.00 1"U'dit Bn Si/ /,.?SQr►s;/ 4.?Sgi�s/ Z?S'Qn St r B- Z /0.75- 99,83 7/0.75 4/1-W On S;/ 4s''Dn r;/# 47 ri, 7'y $n S fl r B- 3 42.54 /4/,S1 /done 7/,2.50 /.//,dXDnl:/ 416 8n,.rdj ,1,78ns/ 9,S/'9.4 s r B- y 9.58 9467 1araIk'8nJ,/, /•.�S'4ns:l /..ts'B»sl 5;d3 8» S { B- /0,0a? 99, 17 Non 6 /0,01? 4/GdK84ril/S 6' B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAT MINUTES NUMBER IN601" AFTER SWELLING INTERVAL-MIN. IOD 2 PERIOD3 PER INCH P- / ,00 &A Y'S O P- ,Z S_ AIA, . 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. 9 SYSTEM ELEVATION 0?, s see- NEYy ( CJ8 '� 3G sole- as I i II f I G — - i. r _ ` - IN $ 4. t p� i I �rfy y I _ _A a0 �� 'n_ _ � ,j, i a 1,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 WER COMPLETED ON: Ro4er A: -swansa•, Tay 9 /9*07 ADDRESS: V CERTIFICATION NUMBER: PHONE NUMBER(optional): R s' /3oA ?"Ver- Fl/s GUIs. s- CST SIG A RE- DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — l ! I , i L IYSTEM ELEVATION 9�, 08 '' SW4 XE Ae K 1-`'�''�' � + �,. l,O� __.;._ � ._.,. •� its n : 1 , i0; el OOLK to Co ad M M , .31S8' /YI1°R-skJ i f -N h 1 0 � -�-. 40 \ ck I d � Q J �1 Pr I Q0 I I � I � I s- I — a w I I � I p m o