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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1 }(m)].
Permit Holder's Name: City Village X Township
O'Keefe, Dan & Roxanne Hudson Townshi
CST BM Elev: Insp. BM Elev: BM Description: ,
pp. rJ I t~ .7 ~ ~ .a.tc~ \ `e.~ Jerl,~'
..~rAf1..AT~A.~ GI GVATIAN I~AT
i r+u~r\ u~rvr~~n~+r rVn
TYPE MANUFACTURER CAPACITY
Septic l~O
Dosing We ~~
Aeration
Holding
ToNK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic ~ ~s r ____
Aeration
Holding
PUMP/SIPHON INFORMATI
Manu cturer Demand
GPM
Model tuber
TDH ' t Friction Loss System Head TD Ft
orcemain Leng Dia. Dist. to well
county: St. Croix
Sanitary Permit No: 399673 0
State Plan ID N
Parcel Tax No:
020-1143-70-000
STATION BS HI FS ELEV.
Benchmark ~ I 3.32- ) 0 3.3 ~ ~, O `
Alt. BM N/~
Bldg. Sewer
St/Ht Inlet u u
SUHt Outlet 1~ f r
f 10 q J• ~6 r
l
fet+ S~Z ~N ~
~• ~3.9 31
Dm~''~Z .S~ 93-x-31
Header/Man. ~ • `~2 93• `fa ~
D~s4-f3i~ ~ ~~ ~' Z• ~' ~
Bot. System ~,~-2, ~/•60`
Final Grade
S•ob" ~
8.2~
St Cover ~~ 3.3~ 9~• 9g 1
JVIL V ~\~ ~ ~V1~ v ~ v ~ r~.. ~~yV~ -~~y-~
id D
th
Li
RENCH idth Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. ep
qu
DIME 3~ 1
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manuf t r r: ~ C;~~~_• n_ _
w+c(l!
CHAMBER OR J
INFORMATION stem:
e Of S
T / ~ UNIT mber:
Mode
yp
y \\/
~O ~
I~ _~ ~
e
.~
r ~
U l
~ ( .
rIICTGIR11TIr11U CVCTFM
Header/Manifold •v•
/' N
Length \Qe- Dia 1 Distribution
Pipes
Length Dia Spacing x Hole S(ze x Hole Spacing Vent to Air Intake
--~. ~~. 1
a/\u /+w~n __ ..__ _ _____ ... __._~_ /._~.. .,...........~ r~. m_[,:ronn %VRiQTS UfIIV
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ! Yes , ;~ No ~ ~ Yes ~ _ j No
~~
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~N/_~/ Z~~ Inspection #2: ~t~ /.
Location: 462 McCutcheon Lane Hudson, WI 54016 (NE 114 SW 1i4 17 T29N R19W) Park View Estates Addn. V{ Lo Parcel No: 17.29.19.
1.) Alt BM Description = (-ems- uls~ 5' C'~Z ~ ~~~ /~ f~~ '~
2.) Bldg sewer length = ~ ~ ,~ .f~~k~-~ ~, ~pts¢~p~G $ s Z
-amount of cover = ~~---.1 / ~ ~ p ~ ~(a: S3 1~ ~ I l • ~"(
`~ ~ / ,
--- - _-- -----, - -I C-1-~-~5~
4
Plan rtes isis de forulddi?ona',] Yes I- No i 3 I ~~~ ~ ~ '' J r- ~-
U o ev.~ ' 3 fJ ~ information. - _~ ~ _~ ~~--~a^' _ -- - -J ~ --
SB~D-6710 (R.3 97 ~ow~C_ V'md Dat~ ~ ~ ~ ~~ Insepct~Si a@n lure , Cert. No.
*~vwc.¢~ -Q-~'s~ '~6'"~.. u'°`S ~"~"'°Q' ~' C°rpr~.~"~, -.~a.,~,l~,
-~R~P~.+sc~
Sanitary Permit Application safety ~ Buaaings Division
`~ In accord with Comm 83.21, Wis. Adm. Code
See reverse side for instructions for completing this application 201 W. Washington Ave.
PO Box 7302
7302
WI 53707
M
di
sconsin -
son,
a
Department of Commerce Personal information you provide may be used for secondary purposes
[Privacy Law, s. 15.04(I)(m) (Submit completed form to county if not
-,_., state owned.)
Attach compl ete plans (to the county copy only) for the t r,no): than 8 -1/2 x 11 inches in size.
County State Sanitary Permit Number ^ Ch i rsion to~previous " is ion
' State Plan I. D. Number
C
~ ~ .
,
~~
I. Application Information -Please Print all Information Location:
Property Owner Name Property Location
~O E ' ~~- ~ JQ: ~) ~ ~ ~~~2 j 1/4S~/4, S TZ! ,N, {or
Property er's Mailing Address )
COUh1T'Y Lot Number Block umber
/~
2 C.. It~ 'S ZOt~1iNEiL~F~ .<: `,y ~'
City, fate Zip Code o ber ,, ~ '~ Subdivision Name or CSM Number2
II. Type of ilding: (check one)
t fT'C,~'
d ^ C'ty
^ Village
rooms :
7
1 or 2 Family Dwelling - No. of Be
-
O Town of
-,FM-,E~ ~t_/~
Public/Commercial (describe use):_ .TLrQ
~+~ffJto'~/ '
^ State-Owned
J 3 x ~ ~ ~
T Nearest Road
C~
~ r r ~s ~ ar T Num )
i
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
A) 1. New 2. Replacement 3. ^ Replacement of 4. 5. 6. ^ Addition to
System System Tank Only Existing System
B) Permit Number Date Issued
^ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check art that apply)
Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland
Pressurized In-ground ^ Holding Tank ^ Single Pass . ^ Drip Line
^ At-grade h ^ Aerobic Treatment Unit ^ Recirculating ^ Other:
5 t ~,s ~ ~kf'~~
V. Dispersal/Tre me Area Information: r
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required. Proposed Rate (Gals./day/sq. ft.) ~(Min./'inch) Elevation
SOD syP. y~ ~ • 7 to. ~ ' "'
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing Crete structed
Tanks Tanks
_~
^ ^ ^ ^
,L,,S'O SD bll7 ~BG~i(J
^ ^ ^ ^ ^
VIII. Responsibility Statement
assume responsibility for installation of the POWT s o~an on the attached plans.
I, the undersigned,
.
Business Phone Number
Plumber's Name (print) Plumber's Signature (no stamps): -#4PJMPRS No.
'/
7/1 ~ .~
umber's Address ( et, City, State, Zip ode)
G~LG d.~/ - ~1a1- x/06
z pZ~~ t ~ ~' p
IX. County/Department Use Only
^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu'ng Agent Signa (No stamps)
Approved ^ Owner Given Initial Adverse Surc arge Fee) _ ~ ~ ~ ~ ~
~
Determination 22S ,
r Dis prove
provaa~ons fo
nditions o
o
C
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~
~
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S~~ _ NJ~.n~MJI~~ Co..~., ; -~,~.^ ~i Utz f9n
-~ _ ~~ .~
SBD-6398 (R. 07/00)
Fogerty Plumbing
' #2?_1180
28~~ 3 ~'cKenzie Rd.
$poc,": "~r, VII 54801
(715) 635-96
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, Fogerty Piumbin~
#2?_1180
28~~ 3 ~ "cKenzie Rd.
Spoc,~.~~r, Vil 54801
(715) 635-96
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Wisconsin Department of commerce SOIL EVALUATION REPORT
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 1/2 z 11 inches in size. Plan must
irldude, but not limited to: vertical and horizontal reference point (BM), direction and ParoeF I.U.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. R viewed by / 1
Please print all information.
personal inlorrnarion you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
party Owner Property Location
r ~~• Lot ~ 1/4~ 1/4 S T
props--~% Ry O~nrtle~a i~A•nling Address ' Lot # Bfodc # Subd. Name ar CSMII
__ 2 ~.,,.,, ~:., c ~ Phone Number ,City ^ Village Town
~p .,, ~) e
N R /9 E
Nearest Road
GPD
Code;tl~~tei3 design flow rate .
,~,~ ^ New Construction Use: esidential umber of bedrooms ___~
Replacement ~ Public or commercial -Describe: ____-_ fl
rrss~~~~..tt~~ _ Flood~Plain'elevation if applicable ~~
Parent material _~L'~7ldli~~~ ----` ~ '
General corrurlents ~ ~~'~ : 9~, P
and recommendations: /rI/~f ~, r ,
•~~ ~~
,r~-=~,
^ Bonng
Bonng #
f
~~'
D
t in.
epth to limiting factor
~ Ground surface elev. Z! •
-
Pit .
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary
Sh.
Sz
Gr
in. Munsell Qu. Sz. Cont. Color .
.
~ 0
,r S
~ -33 '~- ~
~~~ - ~ L
~
a3'
~•! ~ b Al ~~I4f
~ ~Z' ~Z` `
[~ Boring
Boring # ~ Ground surface elev. _- tt.
Pit
Depth to limiting factor ~__-- in.
Date Evaluation Ca
Pd ~~zzj6l~
Page __ ~ o(_ 3
_Eff#1 'Eff#2
.~-;
., ..
and TSS _< 3Q mgll
t:ST Number
/- ~s'~- yoz-~i vd
. -.~ .
Property Owner _~(~~ ~~-scw~
1 ' I a~~M a ~ Boring s+.
Parcel ID # ,~~=~y3 - 7D~ ~J
Idl
Page ~ of ?-
...~ .
Pit Ground surface elev. ___ ~ ___ ft. ep o rmr
Sal ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/(F
in. Munsell du. Sz. Cont. Color Gr. Sz. Sh. 'E(f#1 'Eff#2
_ ~-
, ~ ~ - 2-
~
~I ~ Z6
~.
LJ Boring
Boring # •' ng 1yZ-
pit Ground surface elev. __ Q1_s __- ff. Depth to limiti factor rn• Soil ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rool
~ •E~GPD/fFEff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. +
z ~ s~ !' Z
~~ ~• ~~ Y /
U Boring
Boring # Ground surface elev. _____- n• Depth to limiting factor in.
(~' Pit
tence Boundary Roots
i
C
}
Soil ication Rate
GPDi'fl'
Horizon Depth
in. Dominant Color
Munsell Redox Description
Du Sz. Cont. Color T:,cture Structure
Gr. Sz. Sh. s
ons
'Eff#1
'Eff#2
' Effluent qt = BOD, > 30 <_ 220 mg/L and TSS >30 <_ X50 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS'< 30 mglL
The Deparunent of('omrnerce is an eyual opportunity service provider and employer. If you necd assistance to access services or
necd material in an alternate format, please contact the department at 6U8~66=3141 or TTY 608-264-8777. - -
Fogerty Plumbing
' ~ ~2?_1180
28~~ 3 ~ "cKenzie Rd.
Spot.;~::,~r, Cil 54801
(715) 635-96
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- Sanitary Permit Application -'
/
~` ~arery oc auuumgs vrvraw~
~ 201 W. Washington Ave
~~ •
In accord with Comm 83.21, Wis. Adm. Cgde
See reverse side for instructions for completing thisap~)fcation ~ ~~ Pp gox 730:
WI 53707-730:
Madison
SCOnS~n rovide may be used for sec0ndttry pu oses
ou
formation
P
r
l i ,
nt of Commerce
t p
y
sona
n
e
~
' ~ ~ ~ ~ mit complFted form to county if no
me
Depar [Privacy Law, s. 15.04(1 xm)] ;
-' ~~~~ _ state owned.
Attach compl ete plans (to the county copy only) for the system, on pa nbt less tb 11 incheg in~ize.
County State Sanitary Permit Number D Check if revision to pre 'otrs 4ppl' an I. D. ~ her ~ ~ '7
- ~ t
C
I. Ap lication Information -Please Print all Information ` ` , ~
~
~ Loeation;-'
~,,
Property Owner Name ~'
~ _rbp~ty-r:ocation • .
~. ~~
?O E ~ •• l%4~/4,S T2'j,N, (or
,
Property is Mailing Address
Lot Number Block umber
2 C ~
ity, tote Zip Code Phone Number ~'3
Subdivision N~rtre or CSM Number Z
fail ~/ 0 / c 7~ ) 3!<_ 9/ ~ Ffr~a~s
II. Type of ilding: (check one)
~ ~ Crty
w
C
~
~
~
rd 1 or 2 Family Dwelling - Nu. of Bedrooms : To
n of f ~ , 7i
1 •
,
~, ~
~"
O Public/Commercial (describe use):_ -
^ State-Owned ,dh~ L ~~ S~~
Nearest Road
~ ` Num r)
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
A) 1. ^ New 2. Replacement 3. ^ Replacement of 4. 5. 6. ^ Addition to
Existing Systen
System System Tank Only
Permit Number Date Issued
B)
^ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) , ,
d D Mound ~ • ^ Sand Filter ^ Constructed Wetland
'
Non-pressurized ln-groun
¢1
~p Pressurized In-ground ^ }folding Tank ^ Single Pass • O Drip Line
^ At-grade ^ Aerobic Treatment llnit ^ Recirculating ^ Other:
r -
V. DispersaUTreatme
1. Design Flow (gpd) nt Area Information:
2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Elevation
Required Proposed Rate (Gals./day/sq. ft.) (Min./inch)
SOD
fv.~
SYS'• y!' / . 7 ~ ,...
V11. Tank Capacity in Tutal t! of Manufacturer Prefab Site Steel Fiber- Plastic
lass
C
Information on- g
Gallons Gallons Tanks Con-
Crete structed
New Existing
Tanks Tanks
vr,,o = ua ~
" ^ ^ ^ ^
v~1 2- ~s'
- ~
^
^
D
D
^
VIII. Responsibility Statement
the undersigned, assume responsibility for installation of the POWT shown on the attached plans.
I
,
Business Phone Num r
Plumber's Name (print) Plumber's Signature (no s~ : •.MP/MPRS No.
'/
r ~...~~~~v ~S
umber's Address ( et, City, State, Zip .ode) ^ ' G~L `~•~ _ ~/D1 ~, ~~06
IX. CouatylDepartment Use Only
Disapproved Sanitary. Permit Fee (Includes Groundwat Date Issued Issuing Agent Signature (Nos ps)
'~ Approved ^ Owner Given Initial Adverse Surcqq~~~arge Fee)
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Determination ~+P
X. Conditions of Approval /xeasons for utsapprv`ar: n ,~
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Fogerty Plumbing
~2?1180
Zg~~ 3 ;.'.cKenzie Rd.
$pot:,:_-~r,-1'11 54801
(715) b35-96
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~~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of Z-
FILE INFORMATION
Owner ~~~ ~ /~~
Permit # ~.~
DESIGN PARAMETERS
Number of Bedrooms ^ NA
Number of Public Facility Units ~,NA
Estimated flow (average) U~D gal/day
Design flow (peak-, (Estimated x 1.5) (~ gal/day
Soil Application Rate I • ~p~, d . ~ al/day/ft2
Standard Influent/Effluent uality Monthly average*
Fats, Oil & Grease (FOG) <_30 mg/L
Biochemical Oxygen Demand IBOD5) <_220 mg/L ^ NA
Total Suspended Solids IT$S) 5150 mg/L
Pretreated Effluent Quality Monthly average
Biochemical Oxygen Demand (BODS) <_30 mg/L
Total Suspended Solids ITSS) <_30 mg/L ^ NA
Fecal Coliform (geometric mean) <_10° cfu/100m1
Maximum Effluent Particle Size Y8 in dia. ^ NA
Other: ^ NA
*Values typical for domestic wastewater and septic tank effluent.
SYSTEM SPECIFICATIONS
Septic Tank Capacity rl ZS~ al ^ NA
Septic Tank Manufacturer ^ NA
Effluent Filter Manufacturer ~-~~~ ^ NA
Effluent Filter Model ~_ -~p ^ NA
Pump Tank Capacity al ~NA
Pump Tank Manufacturer ~NA
Pump Manufacturer ~NA
Pump Model ~ f~NA
Pretreatment Unit
^ Sand/Gravel Filter
^ Mechanical Aeration
^ Disinfection
^ Peat Filter
^ Wetland
^ Other: ~[NA
Dispersal Celllsl
In-Ground (gravity)
^ At-Grade
^ Drip-Line ^ NA
^ In-Ground (pressurized)
^ Mound
^ Other:
Other: ^ NA
Other: ^ NA
Other: ^ NA
MAINTENANCE SCHFr)111 F
Service Event Service Frequency
Inspect condition of tankls- At least once every: ^ month(s) (Maximum 3 years)
3 ~ earls) ^ NA
Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA
Inspect dispersal cellls) At least once every: 3 ^monthls) (Maximum 3 years)
year(s) ^ NA
Clean effluent filter At least once every: ^monthls)
Z year(s) ^ NA
Inspect pump, pump controls & alarm At least once every: ^monthls)
^ yearlsl
~A
Flush laterals and ressure test
P At least once eve
ry~ ~ ^ month(s)
^ year(s) ~NA
Other: At least once every: ^ month(s)
^ yearlsl ~NA
Other: ~A
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition .and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third IY3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
_ ~ Page Lof 2-
START UP AND OPERATION
i=or new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s1. If high concentrations are detected have the contents
of the tanklsl removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s1 and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant
replacement system:
^ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
< <WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER
Name I ~£(j,,~ ~
Phone (S- - 36s'~
POWTS MAINTAINER
Name
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
Phone
Name lj j G(Ld (x C~-1~.1~ ~N /
Phone ~'(~ -
This document was drafted in compliance with chapter Comm 83.2212-(b11111d)&If1 and 83.54111, 121 & 131, Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/B~r j,~d/ dt ~y,hi¢,t/it/,~ D ~~~F
Mailing Address ~/`.~ !~! c ~u7r-,,~h~.FD~t/ ~ ~ -~'y~i6
Property Address ,S~>~~
(Verifica/tion required from Planning Department for new construction)
City/State ~Gt jZf4~ ~C~.~~/0~` Parcel Identification Number ®.?O - //j~3 -70 - yy0
LEGAL DESCRIPTION
Property Location ~~ '/,, S~u/ '/,, Sec. / 7 . TAN-Rf~\~i~, Town of ~LG~/JSO~/
Subdivision ~~K y~~ ~S'Ti~/~S" -1 ~~ ~l~f~c^7.~~.t~ ,Lot # .~3 .
Certified Survey Map # '~- ,Volume ~ ,Page #
Warranty Deed # ~e,~ 4 7~ ,Volume /! g ~ ,Page # .Z 4L
. .
Spec house O yes LWno Lot lines identifiable ~es O no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resource, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days~f the three v~ar rrn~r~r.^^ a-~-
..~. O ' _ ~ o/ /ozi ~?
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
~, ~' 4~/D~d~
SIGNATURE OF APPLI ANT DATE
*****' Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. **`**'
a
** Include with this application: a stamped warranty decd from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
` ~...
ST.'CROTX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
~ w ~
N
~~ ~~~
~~i~; 37
~~~~:
,~
~.
This is to certify that I have inspected the septic tank presently
serving the ~~.Z. /yCCvTC/fEOh ~/IE residence located at:
,{/f' ', , ~/ '„ Section ~, T ~9 N, R _ ~ •W, Town of ~.
~U~O~on ... Upon inspection, I ce~y that ~ have found•• •f
the tank and baffles to be in good condition a~ it appears to be
functioning properly . .Z,b ~ : ate- !'~``~s3 - 70 " DD ~ qd oti
Last time serviced: f
Did flow back occur from absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity: ~o~~• p
Construction: Prefab Concrete~~ Steel
Manufacturer: (If known):.
Age of Tank (If known):
~ ~.Q~~
(Signature) ` ~-
~~p ~ ~~~~
(Title
~/a
Date
Other
(Name) Please print
~ ~~~
(License Number)
n
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code )
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certificatidn:
In accepting the above
condition, I certify th~
conform to the requir
inspect~..on open e~
Name
statement regarding existing septic .tank
q the tank to the best of my knowledge will
hts of ILHR 83, Wis. Adm. Code (except for
outlet baffle).
_ Signature MP/MPRS .21 //~
s
~:;: ~ s ~w~' ~ t ~-
yo~ 11~~PACE?(l~
WARRANTY DEED
5489'71
Document Number
Return Address
Parcel I.D. Number: 020-143-70
REGISTER'S Or:FICE
ST. CROIX CO., WI
Recd b Rxad
SEP 3 1996
t~lrrdt]1~
/0~/~.
Laurence W. Schmit and Marie L. Schmit, husband and wife, conveys and warrants to Daniel T. O'Keete
and Roaane L. O'K_eefe, husband and wife, as survivorship marital property, the following described
real estate in St. Croix County, State of Wisconsin:
Lot 53, Pazk View Estates Second Addition in the Town of Hudson, St. Croix County, Wisconsin.
This is homestead property.
`~~ Exception to warranties: Easements, restrictions and rights-of--way of record, if any.
.~
,, <.
~ `' Dated this 30 ~" day of August, 1996.
F:.
~' e' ' ~
.~ ~ / /
-t- (SEAL) _ (SEAL)
surence W. Sc Marie L. Scl t
~t
AUTI~IENTICATION
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Signature(s) Laurence W. Schmit and Marie L. Schmit,
husband and wde, authenticated this ~~ day of
August, 1996.
Knsttna Oglart~l
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristine Ogland
Hudson, WI 54016
AI~aSFER
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DEPARTMENT OF INDUSTRY,
LABOR & HUMAN RELATIONS
P.O. BOX 796:
'~ MADISON, WI 53707
NWT, NE%,S17,T29N-R19W
'~:~r~n' ~ Hudson
~ LOt 53 ParkView Estate
, NAME OF PERMIT HOLDER:
Darrel Wert
} BENCH MARK (Permanent reference point) DESCRIBE IF
I
Name of Plumber:
"> William Schumaker
SEPTIC TANK/HOLDING TANK:
i MANUFACTURER:
^ Y E:
OSING
VENT
INSPECTION REPORT FOR
PRIVATE SEWAGE SYSTEMS
CONVENTIONAL ^ALTERNATIVE
^ Holding Tank ^ In-Ground Pressure ^ Mound
ADDRESS OF PERMIT HOLDER:
1616 Pinewood, Hudson, Wl 54016
SAFETY & BUILDING:
DIVISION
BUREAU OF PLUMBING
State Plan LD. Number:
(lf assigned)
IATF~..~• . ....
~ v ~~~~
. PT. ELEV.: CST REF. PT.
MPRSW No.: County Sanitary Permit Number:
6382 St, Croix 95973
LIQUID CAPACIT V: TANK INLET ELEV.: TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
^YES ^NO ^YES ^NO
iH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
4RM. FEET FROM LINE AIR INLET:
YES ^NO NEAREST
MalvuracluHER: BEDDING: LIQUID CAPACITY PUMP MODE L. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COV ER
PROVIDED: PROVIDED:
^YES ^NO ^YES ^NO ^YES ^NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPER TV WELL: BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM a"E: AIR INLET:
PUMP ON AND OFF) ^YES ^NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I EN , r H uIAMErER MATERIAL ANO MARKwG
or excavation. Ilf soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVFNTIONAI SVSTFM•
BED/TRENCH WIDTH: LE NGTH NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: #Pi TS. LIQUID
DIMENSIONS ~ ~ ~ TRENCHES MATERIAL: PIT DEPTH:
/
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPE&. ABOVE COVER ELEV. INLET ELEV. END. PIPES: FEET FROM LINE: AIR INLET:
NEAREST--
Mound site plowed perpendicular to slope Check the texture of the fill material for
and furrows thrown upslope: mound systems to make certain that it
meets the criteria for medium sand.
^YES ^NO
SOIL CIDVER TEXTURE. PERMANENT MART
^YES
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED
CENTER. EDGES-.
i ^YES ^NO
PRESSURIZED DISTRIBUTION SVCTFM•
PROVIDE A DIAGRAM OFSYSTEM
ON REVERSE SIDE. SHOW ELEVA-
TIONS MEASURED.
OBSERVATION WELLS.
~NO ^YES ^NO
D: MULCHED:
^YES ^NO ^YES ^
WIDTH: LENGTH: LATERAL SPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELE V.. ELE V.. DIA.. ELEV
: PIPES: DIA.:
ELEVATION AND .
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING. GRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
^YES ^NO ^YES ^NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF _
PROPERTY WELL: BUILDING:
FEET FROM LINE:
^YES ^ NO ^YES ^ NO NEAREST
Sketch System on
Reverse Side.
DILHR SBD 6710 IR.01/82)
ISIGNATUR E: I I I I Lt:
li Zoning Administrator
~.~a
~~~5~
:~~
I~
Retain in county file for audit.
"~~ q35
~~ SANITARY PERMIT APPLICATION couNTY
4~ DILHF~
Adm
Code
05
Wis
In accord with ILHR 83 • ~-+
.
,
.
. STA SANITARY PERMIT #
tAttach Alomplete 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. pETlrloN
i. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. IIC~II
FoR VARIANCE ^ YES ICI No
PROPERTY OWNER
~
' PROPERTY LOCATION
~
'
'
,
L ~.~ ? I
/4, S n T ~, N, R E (or}
/a
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER CITY NEA EST ROAD, LAKE OR LANDMARK
/
,(~~~ ~..s1 C/ ~ S'YO/ ~ ~ VILLAGE : ~-
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family ~ OR ^ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable)
^ Repair of an
^ Reconnection of e
^ Replacement of d
1
~ New b
^ Replacement c
a
.
.
.
.
.
.
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
I n-Fi I I Tan k
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ee a e Bed b. ^ See a e 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):
~ ~lS Gl~ /~-'X-~ a~ Feet ~ Private ^ Joint ^ Public
VI. TANK CAPACITY
in allons
Total
# of
'
Prefab.
Site
C
l
S
Fiber-
l
ti
Exper.
INFORMATION New xisting Gallons Tanks s Name
Manufacturer Concrete on- tee glass as
c App
Tanks Tanks structed
Se tic Tank or Holdin Tank G ~ .cs-.rte- ^
Lift Pum Tank/Si hon Chamber ^ ^ ^
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system sho on the attached plans.
Plumber's Name (Print): Plumber's Si nature: (N mps) P PRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code): Name of D signer:
~ ~ ~ - vv -
V I. SOIL TEST INFORMATION
Certified Soil Tester (C ) Na a CST #
~~ P'y
C s AD S (~ et, City, State, Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT SE ONLY
A
d ^ Disapproved
^ O
Gi Sa ~ ary Permit Fee
~ )A Groundwater
Sy~„charge Fee ate Issuin Agent Signatur
e
(No Stamps)
pprove wner
ven Initial ,1 _q~
/ IJIJ (J 41:
~ ~' ~
,,, `
~
~
-~
Adverse Determination
~
V !
/~
`MMENTS/RE ONS FOR DISAPPROVAL:
`
moo dos ~ . ~~ l~v~v
~~t~~ ~~ ~ti~e ~ ~
Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
s s
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 owners name and mailing address. Provide the legal description where the system is to be
installed;
I!. 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;
II!. 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 a//septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/ X 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the ~J~
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground~ratar ~~ `--
included the creation of surcharges (fees) fior a n~~mber of regulated practices which Wiscor~in 5
can effect groundwater. The surchary„ took effect on Juiy 1, 1984. Ail of the water that buried ~rea5ur~ ~ ~ ~~~
is used ir: your building is returned t^ the groundwater through your soil absorption (o
~rf
system or the disposal site used by your holding tanK pumper. U
,~
The !z~onies coilerte<.' through these surci,a~ges ~~.re eretii:>d ,~3 try; grc7unciwaier `und adminis- 'y''
. ~z
r~- er by tiie ,~~epartment of Natural Resource; These funti~5 a+-e u3ed for rr~on~toring ground- '~~,
+.~ _.ie. g~~ 7ur.ciwaier contaminaticr: in<-estigat~ .n; a.ncf ~~;t~t;f~sllm~-get cf standa~d~, ~aroundwat~ ~ , ~_ 7
'''s ~pcrt` ~rotect~ng.
._3irF,~;9P_. ~ i.f73;i)6)
a •
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
Location of Property ~,~ ~'~, Section ~ l , T~N-R 1`~ W
Township '~.
Hailing Ad-dress
Address of Site
Subdivision NamE
:Lot Number
Previous Owner of Property ~ ~J~,,,~'
Total Size of Parcel
Date Parcel Was Crest
Are all comers and lot lines identifiable? Yes (~ No
I• this property being developed for resale (spec house) ? ~.)( Yes No
Volt~e $~ and Page Number C~~' 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 0(VNfR CERTIFICl1TI0N
1 ((oel cen.ti.~y .that a,Q,e statements on xhi~s ~onm wce ~'icue ~o xhe be~.t o~ my (owc)
hnaw~.edge; xl~:at I (we 1 am ( cote) the owners (~s 1 0 ~ the pnope~cty dens chi.bed .tn th,ia
~.n~onma.ti.on 6onm, 6y v.chtue o~ a wa~.anty deed necohded .~n .the 0~~~,ce o6 the
Cou-Lty Reg.usten o~ fleed~s ass Document Na. ~ s ~~ ~~ and that I (G)el nneaen,t,Eu
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ~ ,r„ ~~ ~,~/;~~
ROUTB/BOX NUMBER /~/~' ~,.,,_~ ~ ~~ ~,~n Fire Number
.CITY/STATE ~~c/c~~tJ w ~' ~~~/G ZIP ~t~,s/~'
PROPERTY LOCATION:~~, ~;t, Section_~, T~N, R~W,
Town of ~[ G{,~,SD~ , St. Croix County.,
Subdivision Q~y~~~o+,~~~~',, Lot number J~.3
,/°
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 ma3-
a maximum of 60X of the cost of
which was in operation prior to
accepted this program in August
owners of all new systems agree
maintained.
be eligible to
replacement o
July 1, 1978.
of 1980, with
to keep their
receive a grant for
E a failing system,
St. Croix County
the requirement that
systems properly
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.
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County 7.oning Offia~e within 30 days
of the three year expiration date.
SIGNED __ ~~~~~
DATE, ~~p~-/~0
St. Croix County Zoning Office
P.O. Box 98r
Hammond, WI 54015
715-796-2239 or 715-425-8363
H
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Sign, date and retur
DEPARTMENT OF REPORT ON SOIL .BORINGS AND
INDUSTRY, pERCOLA710N TESTS (115)
LABOR AND
HUMAN RELATIONS (N63.0911) & Chapter 145.045)
SAFETY & BW LDINGS
DIVISION
P.O. BOX 7969
MADISON, WI 53707
LOCATI ~ :N , SE TION; -- O4VNSF MUNICIPALITY: Ol" NO.:BLK. NO.: SUBDIVISION NAnnt: _,,fu4
Nw /4~ /~ i~ /Tz9 N/R19 Ylo W ~DSo~ 53 ~1R EsTMr~3Z"A~D
COUNTY: WNE BU R'S NAME: MAILIN Agg,,DR SS: 540rb
~T C~of~ ..:.--_._-~ ART X616 r /~ ~$cN
Nl OD
DATES OBSERVATIONS MAQE
USE ---- - ~~' P•ERZ`D'CATIa'i~fl4
~- NO.BEDRMS.: COMMER~1 LDESCRIPTION: ~{
Residence TUN ) - New ~~Replace ~Mdy l9 /R~7. MAY za /9~S?
`':UtIC ~O~ AbL Sg SOILS ~Rg~5~`A-k~,OT
RATING: S= Site suitable for system U Site ur-suitable for system ~s._ -_~~ ~ T
O V NTIONAL: MOUND: IN-GFi0UNa1'RESSUR : SYST M-IN•FILL OLDING TANK; RECOMMENDED SYSTEM:(op ion
S ^U DS U C~1S DU ~S ^U DS ~u7~~N~~~r~aN~~
DESIGN RATE: ---- I( an >ot bon of the testrd area is in the
If Percolation Tests are NOT required ,~ Y t N,t
under s.H63,09f51fbl, indicate: ~„ LrdSS I Flondpfttin_inclir_ate Floodplain elevation: (~
~~ ~, PROFILE DESCRIPTIONS
BORING TOTAL P H T UN DWATER-INCHES CHARACTER OF SOIL. WITH THICKNESS, cutruH, t tx n.rrtt, Hrvv vcr r n
C
NUM
BER DEPTf•1'S!< ELEVATION OBSERVED I HESZ K.)
OBSERVEU (SEE ABBRV. ON BA
.T
TO BEDROCK IF
/
B- C Q
(.JU
/~~,~~
~~~~ ,_
~j QQ
--- -/ .OCJ _
r
p,p
' ~~,,pp " //yy S i'~-I~' `,~GS DAN ~S ~ Q
IZ~'glSrCl~ Z.2.--p~NS,C ~6 'QRnI r'I .
B- ~
8.4Z
~o! 7S
N~~~
> g.4 Z .,
,_!a~isrc.n _>z''$4~IS.t ~ bl "ge/~ C~~C>~
B- 3 ~.0~3 X02 .~~ rV~~t:: ? s
.o8_ Zo" g~S, c ~ 2a''BQ,~ S, Z_5'~RN~~~cS e
B- ~ 8 S~ /QI ~ 3 ' VuN_
- _
7 ~:5~ IZ~i&Sr~~ ZO~$~tN~ 1 (- Z., ~.TWT!n- a~s KLI~L_~~'~~~
B' S ____~
8.5'p
/O Z• (1 -
- __
,~ .~
>_Q_SB
J6'~~~5tL7`S 30~$RNS,~ SG~~~ CS ~6~i-R
B-
PERCOLATION TESTS ,
T rDEPTH WATER IN HOLE TEST TIME DROP IN WA1 FR_ LEV _I_ N HES
-"` - -
- RATE MINU(ES
NCH '
PER
NUMBER tS AFTER SWELLING INTERVAL-MIN "-1-
"
PERIOD 1 PERIOD~
- I
-
P. 1
4.99 -
io-,99 .
-
~ _._----
---
> Z _ -
_--..._.
_ __ ~-_\ ~-.-..--
!_ ~~
_
"" "~ -
P- d~'fa AT fe t
P• _^
P--__.- --- ~
E'" ~ -
PLOT PLAN: Show locations of percolation tests, soil borings and the dimen ion oj, a soi areas. Indicate scale or distances. Describe what are the hori
rontal and vertical elevation reference points and show their location on thr, of p r. Show the surfacppe rleva/t~ion at all borings and the direction pod percent
of land slope. - ~ E--qM' CCNG~2QTl FE~„E~sT
SYSTEM ELEVATION ~Zoa _ ~'SC.E ~ ~~sc PAIN -~d OkAt~~ ~Nt@RLtN '
Lpu~T -_ ~ M~GAJ~Tc'wEOt'1
--------- [t.EV = FUO.06
- >f;AftD
~;, = a r~+.~ .o t7 .'~; L is $_ 1 _ q Z ' I
F.,.,~ /.~,s~'~, i,,, ~ 3
i~° ~ W/LLOWB ~ ~ \E---~-- /I
+ "I ~ V,~ ~_. ^ •arv~iv _T `~'~ /~ AI.YtRNA1 ~ t
w r . Q. T~t/v /aof
V " A.oc,6 O a i ~+nJ CO~+"
;~ y~e ~ PARK . ~
~' ;+~„ ~'A~r _y .,,~ p~.J. ! n1oTC: S~aPE IN
.-~.~,
,..~«' 4~ w •~~ ~ 5{1~ ~&~~ 67 ~ d~E+4 IS MINIM~~- ~N
io ~ ~(oi~~r. ~ ~drti ,+ .~,~Q~. 4 ~'.. N ~ f ~ ~~ 7. .. ~ ~ ~ ~ .7L/~L f:.
c. ~ 9c ..
_ - TR uT Br,t,~ ~ ~`~ p
C/a.~V <' c we oe-` Wept `~ .i~3 ~
~q.P 4.y rorn.2 ... . /
' - • • ~ BE q79` 'J9 : J
/6.7 76 r ~S ~`--~-~. /
pp cr • q R
A~. ,m ~~. ohr14~ Q~ 4. I / ~+
~~
I
_. --~-~C~N~R~tN~ t _
', DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIV1510N
WQUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS ft-aa!t nsll7l R Chanter 145.045)
l OCAT10N:N 5E~ION: _ Y ~ OWNS UNICIPALITY: .Ol" NO.:BLK. NO.: SUBDIVISION NA E: ~
fisTKTrsZ"A~D
53 ~
Nw '/~~'/ ~ I
7 /Tz9 N/R19 Flo W ~aso~J
COUNTY: WNER S NAME: MA t_IN A DR SS: ~ A O/~
D /'~ ~SoN i
~ /6 1 tN
~1' C~~ I~ E 4
ERT /
neTCC nRCt:RVOTIANS MADE ~ ~ -
~,F _ ______
.Residence - -!
NO.BEDRNIS.:
~~ N
COMM R ~f)ESCRIPTION:
~ -
,~( (-~
J!L,1 New -
"':ttrlt t~yOK. ~gbtr ~ -'
RATING: S= Site suitable for system U= Site unsuitable for system r_
S DU IBS DU
--~ I~-~~g~R7P'' F~fCATfO1V TESTS:
Replan L Mdy - /9 r9~7 May 7v r~~
SOILS -',~^"~0.~g - DAkOT14
__ G.dg. -_ ~M M
ING 7ANK• RECOMMENDED SYSTEM:(op ionall
CoN ~(~nIT'l oN~tl
S ~_- --- ---- --
DESIGN RAl F:
If P@rcolation Tests are NOT required II anY ttcn tiort of the testy d •rrr..r is in the ~~
under s,H63.09i511b1, indicate: `Ls45S I Floodplaur, indicate Floodplain elevation:
~~ G, PROFILE DESCRIPTIONS
BORING
NUMBER TOTAL
DEPTHS
ELEVATION P H T R UN
OBSERVED DWATER-INCHES
E __ GNES~__ CHARACTER OF SOIL WITH THICKNESS, COLVR, itxtunt, Htvu utrm
TO F3EDHOCK IF OL3SERVFD (5EE ABBRV. ON BACK.1
B- f > q • dG Iz"gas tt 1s 22"$eNS C S6",$R~ r'1 s~~e t8 $acN CS~L~ ~
B- ~ 8.42 ~o17S N~>v~ > g_a Z _~., f.SrL~ 2Z''$t:r~S-~ 6(`i~e CSC ~
B- ~ C4. Jf3 /p2 .c,3 fV~+~t:: > 8
08 20" BSS r ~ Ts ?o~8ef~ 5,1~_!~7~~lgRN CS~E6 +~
8- ~ BSo io~.93 ~~;---- _
.
> B.So
--- -- f2''gLSt(.n 2v"Bat~'~l l Z.~LY S ~s~GQ
__ ~4..._.. __
B-~
~.Sd
/d~•~~
.~n ,: _
~8•sd ,. •,
/6 $t,StCT`s 3o RNSrI S6 tx'NCS~~iR~
B- -- -- ---------_ ---------- --------____---- ----_-.------------
PERCOLATION TESTS ,
TEST ,DEPTH WATER IN HOLE TEST TIME DROP IN WA1 ER LEVEL-INCHES RAT MINUTES
'
NUMBER l3s~ddtS AFTER SWELLING INTERVAL-MIN t
OD 1
pER pERIOD 2 -! iNCH
ER
~
P. 1 4.9 9 o ro 1,9 9 .
3 -_
.
______
-
> 2 . -___,
_
--------- __-
~..- ~ ,
-
P. 3 97 E o . 7 3 72
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PLOT PLAN: Show locations of percolation tests, soil borings and the dimen~ronk~~~~fte soi v~eas. Indicate srale or distances. Describe what are the hori
zontal and vertical elevation reference points and show thrir location on the ~ut p t. Show the surfacppe elr+.vatirnt ar all borings ;~rxl thx directinit arrct {tercent
of land slope. ~t ~--DM- CpN~~-l FE~P4ZT
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