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HomeMy WebLinkAbout006-1017-90-000 St. Croix County Planning and Zonin Thursday, September 22, 2005 at 10. 32.08 AM Detail Sanitary Information Page 1 of I Computer 006.1017-90-OW SublPlat: 40 acres Section: 8 Parcel 08.31.16.114B Lot: TNIRNG: T31N R16W Municipality: Cylon, Town of CSM: 114114: SE 114 SE 114 Owner: Taber, Dale 2191222nd Avenue Deer Park, WI 54007 State Permit: 79146 Issued: 0511611986 POWTS Dispersal: Non-Pressurized In-ground Permit: Replacement County Permit: 0 Installed: 0512111986 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Ins ector As Built Plumber Other Recuirements Additional Notes Money Owed Tom Nelson Yes Bird, Byron Jr. Entered from pumping notice - found permit 100 $0.00 Signed Off: Yes gal. Weks tank to 12'x 55' bed, 125' south of 222nd Ave. Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 911012003 9110/2006 5/2111989 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I TABER, DALE SE SE, Section 8 R T31N-R16W, te' 01 q~ Town of C ton Deer Park, WI 54007 Y _ San,Permit#79146 5-16-86 B. Bird, Jr. Conventional, Replacement INSTALLED 5-21-86 Parcel 006-1017-80-000 09/08/2005 12:53 PM PAGE 1 OF 1 Alt. Parcel 8.31.16.114A 006 - TOWN OF CYLON Current )(I 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 DALE R & COLLEEN TABER O - TABER, DALE R & COLLEEN 2191 222ND AVE DEER PARK WI 54007 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 0119 AMERY SP 1700 WITC Legal Description: Acres: 36.000 Plat: N/A-NOT AVAILABLE SEC 8 T31 N R1 6W SE SE EXC E 254' OF W Block/Condo Bldg: 554'OF N 209'& EXC W 210'OF E 405'OF N 312'& EXC P1 14D & EXC THAT PT OF Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) PARCEL DESC 1004/22 08-31 N-1 6W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1004/22 WD 2005 SUMMARY Bill M Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 09/08/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 35.000 4,300 0 4,300 NO UNDEVELOPED G5 1.000 100 0 100 NO Totals for 2005: General Property 36.000 4,400 0 4,400 Woodland 0.000 0 0 Totals for 2004: General Property 36.000 4,400 0 4,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 6 00 Parcel 006-1017-90-000 09/08/2005 12:52 PM PAGE 1 OF 1 Alt. Parcel M 08.31.16.114B 006 - TOWN OF CYLON Current LX1 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 DALE R & COLLEEN TABER O - TABER, DALE R & COLLEEN 2191 222ND AVE DEER PARK WI 54007 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2191 222ND AVE SC 0119 AMERY SP 1700 WITC Legal Description: Acres: 1.500 Plat: N/A-NOT AVAILABLE SEC 8 T31 N RI 6W 1.5A IN SE SE COM NE COR Block/Condo Bldg: SE SE, TH W 195' TO POB; TH W 210'S 312 FT, E210' TH N TO POB Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 08-31 N-1 6W M Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 528/212 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/26/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.500 15,000 284,000 299,000 NO Totals for 2005: General Property 1.500 15,000 284,000 299,000 Woodland 0.000 0 0 Totals for 2004: General Property 1.500 15,000 266,100 281,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 512 Specials: User Special Code Category Amount Special Assessments Special Charge0s0 Delinquent Chare00 Total 0.00 U . Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /a X r TOWNSHIP y lell~' SEC. T N-R~W ADDRESS1 b c ~r cc~ ST. CROIX COUNTY, WISCONSIN t.~l f'S~ 5 ~foo SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I114R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM cp 913 vtNr 37 y 384/ . R ~ to S INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used $ 6 k), 51 C% o i/oas Elevation of vertical reference point: 10'0 Proposed slope at site: $ SEPTIC TANK: Manufacturer: KS Liquid Capacity: Number of rings used: Tank manhole cover elevation: f~ ~l Tank Inlet Elevation: 3 Tank Outlet Elevation: A, 5 3 Number of feet from nearest Road: Front ~Side10 Rear O 75 feet .From nearest property line Front 19 Side 10 Rear, 0-0 feet r Number of feet from: well 51 building: 2!2 / _ (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SFF DVXY DCD OT"V PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 'f4ASz- Trench: Width: /Z LenAh : .5~ Number of Lines: Area Built: 6 3,0 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ® Rear,0 Ft.IA f'~' Number of feet from well: Number of feet from building:3 (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, © Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7989 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING ENCONVENTIONAL ❑ALTERNATIVE Stale PIon 1.0 Number: ❑ Holding Tank ❑ In-Ground Pressure El Mound of .eegnad) NAME OF PERMIT HOLDER: ADDRESS OF PEF~ T HOLDER: ,INSPECTION A E: Dale Taber Rt. 1, er Par k, WI 54007 J-aJ-~'6 "~p•~ BENCH MARK IPermanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV,: CST REF. PT. ELEV.: SE14 of the SEk of Section 8, T31N-R16W, Town of Cylon Name of Plumber: MP/MPRSW Nn.. Cnunty Sanitary Permit Number: Byron Bird, Jr. 3318 St. Croix 79146 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER ~ PROVIDED: PROVIDED: 10 YES ❑NO ❑ YES O N BEDDING: rVEN DI VENT MATE HIGH WATER NUMBER OF ROAD: P OPERTV WELL: BUILDING: VENT O FRESH ALARM FEET FROM L~IN^'~'AIR INLET: ❑YES ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP;SIPHON MANUF AC rtIHEH WARNING LABEL LOCKING COVER ❑YES ❑ NO PROVIDED: PROVIDED: GALLONS PER CYCLE: PuMPANDCONTaOLSOPERATIONAL ❑YES ❑NO ❑YES ❑NO (DIFFERENCE BETWEEN NUMBER OF PHOPE HTV WELL BUILDING V N FRESH FEET FROM LINE AIR I NLE LET: PUMP ON AND OFF) ❑YES ❑NO NEAREST-- 0. SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing „ JDIAMF TEH 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.) AIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO OF DISTR PIPE SPACING COVER BED/TRENCH THENCHFS INSIDE UTA -PITS LIQUID EHIAL DIMENSIONS PIT DEPTH. D PTH FILL DEPTH UISTH . PIPE U ISTH PIPE DISTR . PIPE MATERIAL NO DI. IT NUMBER OF BELOW PIPES qB V~COVER E~IN EF EL END PROPERTY WELL. BUILDING. V NT TO FRESH PIP S FEI LINE f(C AIR INLET t < NEARESTO---, . (TV V J MOUND SYSTEM: Mound site plowe 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- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. OIL COVER TEXTURE PF HA:IANF NI MAHKF HS OBSERVATION WELLS DEPTH OVER TRENCH BED DEPTH OVER TRENCH HEU ❑YES ❑N0 ❑YES ❑NO CENTER EDGES DEPTH OF TOPSOIL DDISEE UFU MULCHED ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH 'MOTH. LENGTH TRENCHES 70 -OF LATERAL SPACING GRAVEL DEPTH HE LUW PIPE FILL DEPTH ABOVE COVER : DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATE7-ATE UISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND LLE V.. ELEV.. DIA. ELEV. V. S DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVL VERTICAL LIF T CORRESPONDS TO APPROVED PLANS ❑YES ❑N0 ❑YES ❑NO COMMENTS: F"'MANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑N0 NEAREST 1,'A tt7A V~X~C~ I l c ~t ---rc. ~ ca/Ls Sketch System on /V' /f GJ county file for audit. Reverse Side. SIGNATU TITLE. DILHR SBD 6710 (R. 01/82) A ~ wlsconsln -a APPLICATION FOR SANITARY PERMIT D ' LHRC~"DiX COUNTY O (PLB 67) - InOUSTRV,LgBOR 6NUTRn gELRT10n5 UNIFORM SANITARY PERMIT # -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPER Y O NER MAILING ADDRESS ~c Gt y- c GcJ _Zltz PRO FE Y LOCATION CITY: 1/4 1/4, S $ , T31, N, R 6 E (or ~I N GF; 1/7 LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST RO LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVEDQ 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair i~ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF T IS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench [l Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total *of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: tsC IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total *Of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): L3 6//S a Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatu7.9 y MP/MPRSW No.. Phone Number: / (6 xi Plumb Add resi: Name of esigner: _ O/ r COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee:: Date: oC J J ❑ ❑ Disapproved Owner Given Initial "f/. Approved Adverse Determination Reason for sa rov Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County; One Copy To; Bureau of Plumbing, Owner, Plumber ~ i INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 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 ~Q Q ~p 2 r Location of Property SE ' S E 1%, Section , T 3( N-R IG W v~ Township C y to Mailing Address et, ( 8o x 100, p~e-e-r Po r k LJ cs ~ yo o -7 Address of Site ( 17 2~•~- Park 'Lil-s' Subdivision Name Lot Number Previous Owner of Property Q4 Y~ v\ iS k V~YhY C Total Size of Parcel 44() AeY-e S Date Parcel was Created U, ( l9 -7 Are all corners and lot lines identifiable? ✓ Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number 1( g as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) eenti jy that act 6tatement6 on th.ia .6o1hm ane true to the beat o6 my (oux) know.eedge; that I (we) am ( cute) the owneA (e) o6 the pno pent y dea eh f bed in th,i a .in6o4mation 6onm, by vi tue ob a waivcanty deed neconded in the 066.ice o6 the County Regtiatea o6 Veed6a Document No. 3 3 H ; and that I (We) pneaentty own the pnopoaed bite 6oh the sewage d pod dyd em (on I (we) have obtained an eaaement, to nun with the above dedcnibed pnopenty, bon the eonstnueti.on o6 said eyetem, and the .name has been duty %econded in the 046.ice o6 the County Reg,ieten o6 Deeds, as Document No. 3~3 "aa H 1 SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 15 - DATE SIGNED DATE SIGNED • H z En H a STC-105 r a SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County z t7 OWNER/BUYER 0.b -c r y ran ROUTE/BOX NUMBER 2 T (j o f $y Fire Number CITY/STATE ZIP 5C4OCD PROPERTY LOCATION: s S Section p T 31 N, R t W, Town of O h , St. Croix County, Subdivision Lot number • I 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 pdt 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 E I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED' DATE S~ St. Croix County Zoning Office P.O. Box 9&= Hammond, WI 54015 715-_7.96-2239 or 715-425-8363 Sign, date and return to `above address. 77 "ScUr"M SANITARY P D ILHR ERMIT County GROUNDWATER SURCHARGE " Sanitary Permit Ho. '19/Yro On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com- monly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. E gna a of Issuin Ground oil ge Groundwater Fee: Date: WISCO 5 /p'dV buried tt+yl~t8 DILHR SBD•72 . 051 Y DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION 7969 LABOR AND, PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN RELATIONS (ILHR 83.09(1)& Chapter 145) LOCATION: ~ SECTION: N/R/ E (or NS MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: S;Grole_ ro-Acn rX 5~ 00 USE DATES OBSERVATIONS MA 5E NO. BEDRMS.: COMMERCIAL DESCRIPTION: ❑New PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence Replace ( /j ~/r RATING: S= Site suitable for system U= Site unsuitable for system 7 j,(O ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ®S ❑U WS ❑U 9S ❑U ❑S U ❑S ZU wl-1.5- s f If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: JZ_ Floodplain, indicate Floodplain elevation: O PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEr H IN. ELEVATION OBSERVED ES HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 0 0 -/4 0,7 45 AV -:5 5 B- 3 / lyeiI a loc~r•~i~ sloryr .'Z~`//~J--rte I11~i~ .rjf 48 f~i Sl /e d4,-, 5~r 4-'0 -AV B- /00 l 5 f 1~ ~p !®O 11~is ~i p 7100 B- J • B- B- ~«t PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IPA0016S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R D PER INCH P_ I. P- P- P- P P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 701/ r r _ j i I i 3 ~ 5 } . o E n , , F N tx- Lo r a ~~'~ff 1G ~ 7 i 3 € i i I z _ J-_. 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: C`O`I 46 ADDRESS: CERTIFI ATION NUMBER: PHONE NUMBER (optional): Pr /rSU pp t 7/S G~1~/ CST SIGN RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD-6395 (R. 10183) - OVER - COMPLETIN' o 1 ;~rci ac~f.i star report m::. - 1. Cornpi ;re le--l description; 2. The use'SOcaiOn "lust clearly "('irate wn" - -Ills is a rrssit3 s~£;e ~r ccamn~erc; al I>rojec~L; 3. MAXIMUM ni.irnber of bedrooms or c_ mr ~ ise planned; 4. Is tits ;i new or replacement system; 5. Cor the suitability rating boxes, A SITE IS SUITABLE FOR A HOLDING TA"-"~ ONLY IF ALL OTHER SYSTEL,3 ARE RULE" OUT BASED ON SOIL CONDITIONS; b. PLEASE u; tl a' _ ~wiatioras shown here for writing profile descriptions and cor. . "rtg the plot elan; J. IMAKE A L cT€ rrti~r accuiately locating your test locations. Drawing to is )referred. A separat as sheer y be used t desired; B. Make sure your benchmark and vertir €i elevation efetence point are cle: ~ a permanent; i ) . Conzplet€e all appropri~st.e. boxes as t€3 cites, Harries, addresses, tlc>od plain c.___> , -i test exern6 Lion, if appropriate; 10, If the inforn ion (such as flood plairl, elevation) does not apply, place N.A. in the appropriate box; 1 1. Sign the form and place your current address and your certification nurnber; 12. Flake legible copies and distribute as required. ALL SOIL 'T`ESTS MUST BE FILED WITH THE LOCAL AUl l-IORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS OR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st Slone (over 10") BR - Bedrock cot) Cobble (3 - 10") SS Sandstone - Gravel (under 3") LS Limestone Sand HGW - High Groundwater a c9. fir,, Petcol,at'on Rate med s Me£ iumt ` inn W - UdeiI fs Fine Saild 81 t; Bt ii if Ii1,1 s Loamy Sand ~rsl Sandy Loam < I Loam Bn Bro,,:vi) sil t L€. ai l Cal Black y - Gray sc:l iy Loorn sic:' ~ Glay Loarn mot Clay uti; Sc sic Clay fft IV, Pine, faint `c; C :ly cc common, coarse tat Peat nom - Many, mediurn Muck d distinct p prominent HWL High vijatei level, :.I s€ail t:c:xtur3=s surfac . fc: flqui£t waste, disposal BM Bench Mark 'ARP - Vertical Re` rence Poch TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. 'PROJECT ADDRESS / ~r , s S Y~ o • 1/45 1/4/S-5/T,7/N/R/~-W TOWN G COUNTY-16f,::iz~ 'BEDROOM CLASS PERC_, / CONVENTIONA14iCONVENTIONAL LIFT_ MOUND HOLDING TANK IN-GROUND PRESSURE ~I¢~J SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION A 602 PERC RATE Z- BED SIZE /atX 5'~ PLUMBER LISCENSE NO. DATE ~~/BM ssume elevation 100' Ld' ca 'on of Benchmark Trp O-5 s/ /YX/d d ~ m ys- Q Borehole O well • Perc Hole System Elevation >o TYPAR COVERING /2.. 2.. 2.. 2" 12'. ) C1 Y 4' 4 ) 6" Sewer Rock i 12 ft. 18 ft. 4 ft. Zfp C(Grc 0"lcv'CC/ ~ as 40 010 a ~d I~r b $ aOki r for ~,r~ s7;.s~ Tres ~ r ~~s y eq/ 0