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HomeMy WebLinkAbout016-1025-75-000 St. Croix County Planning and Zoning Friday, February 02,2007at3:27.35PM Detail Sanitary Information Page 1 of I Computer 016.1025.70-M Sub/Plat: 40 acres Section: 12 Parcel 12.30.15.193 Lot: TNIRNG: T30N R15W Municipality: Glenwood, Town of CSM: 114114: NE 114 NW 114 Owner: Stansbury, Roger 1681 Cty. Rd. X Glenwood City, WI 54013 State Permit: 79141 Issued: 0510611986 POWTS Dispersal: Non-Pressurized In-ground Permit: Replacement County Permit: 0 Installed: 05107/1986 POWTS Detail: Trench - Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/inspector As Built Plumber Other Reauirements Additional Notes Money Owed Harold Barber Yes Myers, Lyle tank not replaced, just 2 trenches 5x 76 $0.00 Harold Barber Signed Off: Yes Maintenance Scheduled Puma Date Pumped 1st Notification 2nd Notification 3rd Notification 51712006 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ©t4' to z s~-~6t =0~ 'f STANSBURY, ROGER NE NW, Section 12 gam- T30N-R15W Glenwood City,'W1 54013 Town of Glenwood San.Permit#79141 5-6-86 L. Myers Conventional, Replacement INSTALLED 5-7-86 I Parcel 016-1025-70-000 02i02i2007 03:21 PM PAGE 1 OF 1 Alt. Parcel 12.30.15.193 016 - TOWN OF GLENWOOD Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - STANSBURY, DANIEL R & JULIE A DANIEL R & JULIE A STANSBURY 1681 CTY RD X GLENWOOD CITY WI 54013 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1681 CTY RD X SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 12 T30N R15W NE NW Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 12-30N-15W Notes: Parcel History: Date Doc # Vol/Page Type 08/31/2001 655393 1711/106 WD 07/23/1997 427/610 2006 SUMMARY Bill Fair Market Value: Assessed with: 165271 Use Value Assessment Valuations: Last Changed: 07/26/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 31.000 2,700 0 2,700 NO UNDEVELOPED G5 3.000 1,000 0 1,000 NO AGRICULTURAL FOREST G5M 4.000 4,000 0 4,000 NO OTHER G7 2.000 9,000 103,900 112,900 NO Totals for 2006: General Property 40.000 16,700 103,900 120,600 Woodland 0.000 0 0 Totals for 2005: General Property 40.000 17,500 103,900 121,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 112 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S~$S d 0 WNSHIP ~Uu, ,J' SEC. /~2_ T 3,DN-R_Z~CW ADDRESS Z ST. CROIX COUNTY, WISCONSIN l` ~~C ~ db l i ~t SUBDIVISION LOTI LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 00 CD f 01 ~t tt 3 cl~ 4PR7C7 la T~ n~c t-r ,~C VT- P_x 49 2y, I ~ bus INDICATE NORTH ARROW /0 'T ~ t) Rol. BENCHMARK: Describe the vertical reference point used /iE.z4A' &e1 Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: C12- Tank manhole cover elevation: Tank Inlet Elevation: 112 S~ Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side JgRear, O feet From aaearest property line Front 10 Side ,oRear, O _ Z feet Number of feet from: well / l~ -t building: 3 Q ` (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE RRUi'"I" s , PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: L1 S Width: Len$th•.e Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, 0 Side, O Rear,0 Ft. Number of feet from well: 0~0dq 4J,5 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: F Dated: V Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUILDINGS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned) t NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER Roger Stansbury Rt a 2' INSPECTION GATE: G Glenwood City,, WI 54013 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: NE NW, Section 12, T30N-R15W, Town of Glenwood REF. PT. ELEV.: CST REF. PT. ELE Name of Plumber: MP/MPRSW Nn._ County Sanitary Permit Number: Lyle Myers 6219 St. Croix 79141 SEPTIC TANK/HOLDIN TANK: MANUFACTURER: p LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV WARNING LABEL PROVIDED: LOCKING COVER 9 PROVIDED: BEDDING: ENT DIA.: VENTM Tl HI(iHWgTER DYES ONO DYES ONO ALARM NUNIBE OF ROAD: PROF ERTV WELL BUILDING: II VENT TO FRESH YES ONO FEET FROM „ A1R Iry LET O : DYES ONO NEAREST 3 DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MI)DEL PUMP; SIPHON MANUf ACTIIH EH WARNING LABEL LOCKING COVER DYES NO PROVIDED: PROVIDED: GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL 1:1 YES ❑ NO ❑ YES ❑ NO (DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL BUILDING V NTTOFRESH PUMP RAND OFF) FEET FROM LINE AIR INLET: ON ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing or excavation, (If soil can be rolled into a wire, construction shall cease until L FORCE uIAMF TER MATERIAL AND MARKING the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: BED/TRENCH LEfYJH NO. UISTH PIPE SPACIN(I COVER WSIDE UTA PITS DIMENSIONS / THE cHFS HIAL: PIT LIOUID DEPTH: 1 4 GRAVEL D P H FILL PTH DI ST fI. PIPF UISTH PIPE DISTR. PIPE MATERIAL N STH BELOWPIPES ABOVECOVER ELEV. INLfI EE V.ENU NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH ? FEET FROM LINE / AIR INLET: ~ ~d ~ NEAREST---~► S~' MOUND SYSTEM: !Ydr . 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- OYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PE HM ANf NT M11AHKf HS OHSEH NATION WELLS DEPTH OVER TRENCH BED DEPTH OVER TRENCH HEU DYES ONO OYES ONO CENTER EDGES U[PTH OF TOp5OIL )F 1) ISEED,., JMULCHED DYES. ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIOTH LENGTH OF LATERAL SPACING GRAVEL DEPTH HELOW PIPE TRENCHES: FILL DEPTH ABOVE COVER. DIMENSIONS MANIFOLD PUMP Mil OLU DISTR. PIPE MANIFOLD MATERIAL NO UISTH p15T R. PIPE UISTHIBUiION PIPE MATERIAL MMARKING ELEVATION AND ELEV.. ELEV. DA. ELEV. PIPES DIA: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHECTLY COVER MATERIAL PLANS CAL LIFT CORRESPONDS TO APPROVED COMMENTS: OYES ONO OYES ONO PERMANENT MARKERS: OBSERVATION WELLS: (NUMBER OF PROPERTY WELL: BUILDING: FEET FR EARESTOM LINE. ❑ YES ❑ NO ❑ YES ONO N Sketch System on Reverse Side. Retain in county file for audit. SIGNA U E. TITLE: DILHR SBD 6710 (R. 01/82) wls`on51r1 APPLICATION FOR SANITARY PERMIT COUNTY ~ DILHR aulc~y (PLB 67) - OEPRRT TEI"IT OF UNIFORM SANITARY PERMIT # In..T.Y, LRBOR 6 HumRn RELRTIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/ix 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS /Roe; ~ 4! a PROPERTY LO,,C~~'TION CITY: S-10 113 1 /41671 /4, S N. R 5- E (o W WN OF /e- Wood LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST i AD, LAK OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED - ~Q S-- 7d O ?03r 2 Family Number of Bedrooms: 3 Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair X Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed ,`Seepage Trench ❑ 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 9An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total *of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity d0~ Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: 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): 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): Signature MP/MPRSW No.: Ph (7 S1 e one Number: Plu er's Address: Name of Deess''gner: o? 0 C --d C. L e57. 1 i COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: L Fee: Date: ❑ Disapproved ❑ Owner Given Initial Approved Adverse Determination Reason r Di pr j~Al. Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 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 ~Ia Yl Location of Property Section 169 , T 3C~ N-R W Township Mailing Address f7~ ~ e. / L` _ "Address of Site J a n Subdivision Name Lot Number Previous Owner of Property 4~ Ame SS St t--, r Total Size of Parcel l~ Date Parcel was Created .,S4L/ L~. & I Are all corners and lot lli/nes identifiable? Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume .4,22 and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ceAti.6y that a t .6tatement6 on th-i.6 6otm ahe true to the beat o6 my (oulc) knowledge; that 1 (we) am (ahe) the owneA (.a) o6 the ptco peer ty deb n bed in this in6 mation 6ofrm, by vixtue ob a wavunty deed neconded in the 066ice ob the County Regi6ten o6 Deeds a6 Document No.p7 9 and that I (We) pnesentty own the pnopozed .6 to bon the sewage di.6pos 6ystem (on I (we) have obtained an ea6ement, to nun w.i,th, the above deschibed pnopeJcty, bon the condthuction o6.6aid z ydtem, and the.came ha6 been duty neconded.in the 04jice ob the County Regi6ten o6 Deed6, a6 Document No. SI TURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICAS ) Z-y DATE SIGNED DATE SIGNED w ~ H z cn • H a ST C- 105 r' r ' a SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County z tv OWNER/BUYER y t~ ROUTE/BOX NUMB R Fire Number l~ .CITY/STATE 41 1 ZIP PROPERTY LOCATION:/VL 14 Section o~ T N R --,3 1- , , _W , Town of h 9> 60 , St. Croix County, Subdivision 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 E 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- 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 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. SANITARY PERMIT county ILHRGROUNIDWATER SURCHARGE sanitary Permit No. D ' CF ~ ,,,,,eor+`►.,,wr+rr~.bns l ~ ~ J All isconsin Act 410 was signed into law. This legislation is more com- On May 4, 1984, 1983, W ter protection law. This change in statutes was the result of over roundwa roundwater bill included the creation of monly 2 years ofknown as steady t negotiation and public debate. The g for a number of regulated practices which can effect groundwater. The ur build 2 yea surcharges (fees) our holding took effect on July 1, 1984. All of the stemtorthe d used sposal s to usediby y is returned to surcharge soil absorption sy the groundwater through your adminis- tank pumper. rota hthese surcharges are credited t tithe used for groundwater monitorin g fund ground- are The monies collected th 9 blishment of standards. Groundwater, tered by the Department of Natural Resources. These funds roundwater contamination investigations and esta water, g it's worth protecting. Ground ate Wisco ` in's ' buried e > 11 - Groundwaiff=f;~] z ` k A nt: signature of issuing gti ' b' nag SOD-72 (N. 1 k ~w GEC' •y, _ DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, VISION LABQR AND P.O BOX 7969 PERCOLATION TESTS (115) DI HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) MADISON, WI 53707 3707 LOCATION: SECTION: TO N /MUNICIPALITY LOTNO.:BLK.NO.: SUBDIVISION A E: '/a K0/4' /T,30 N/R 15 E (or ~ 4~ COUNTY: OER'S BUYER' NAME: MAILING ADDRE S: ii "DAJ USE DATES OBSE RVATIONS MADE ~-1 NO. BEDRMS.: COMMERCIAL DESC IPTION: L11 esidence PROFIL D $$$CCCRI TIONS: ER O A N TESTS: ❑ New L"7Replace L77/I RATING: S= Site suitable for system U= Site unsuitable for system ONVFf~flp❑NAL: MOU IN-GRO ~ URE: SYaSTEM-IN-FI HOLDING TA RECOMMENDED SYS;EM:(option r~,-xJ U U S S 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: &4--] 1 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D PTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF.OBSERV (SEE A BRV. ON ACK.) aQ r? r7 r2 Ok nsjl, n sK,/, ,5 n 1111115 63 ?ff .~3 > 79 ° 8t)s//i !7 r3hsicl, / !11 s , 3a y n s FB-T' TESTS NU BER INC ES AFTERSWELOLING INTERVAL-MIN. DROP IN WATER LEVEL-INCHES PER OD 1 PERT D 2 RATE MINUTES P PER PER INCH 0 ~ ~ BCD P- 07 IL 0 r 0 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 I y a .~i = _ € ! A.I r N 1 AM ~v w_ 11100 ce I, the undersigned, hereby certify that the soil tests is form were made ~ Administrative Code, and that the data recorded and the location of the tot are or ectt he b st ofof m d candrbelief, methods specified in the Wisconsin FAD ME (prin TESTS WER COM LETED ON: DRESS: 'y CERTIFI ATION NUMBER: PHONE NUMBER(option I): * 6-,~ CST SIGN RrE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - L I - i =ONS OR C MPLET I- 115 - SR To be sa c:ontplete, and accut,ate soil test, your sport must 1, Complete leclal description; 2. The use Section Must clearly indicate whether this is a r iderace or conanlercial project; 3. MAXIMUM mumber of bedrooms or commercial ~r d, 4. is th[s a new or replacement systein; . Complete the s altalsility-rat:irag boxes. A SITE IS SUITABLE FOR H34-DING TANK ONLY IF ALL OTHER 5`t' I ARE RULED OUT BASEL) ON SOIL CONDITIONS; 6, PLEASE u, eviat ions shovjn here for writi€ig profile descriptions acrd completing the plot elan; 7. MAKE A a diagram accui,ately locating your test locations. Drawing to scale is preferred. A separa a <y be used if desired; B. Make stare y ~ vrichmark and vertical elevation reference point are clearly shown, and are permanent; 9. x rr>giriat.e. boxes as to dates, nary}es, acldressa~ , flood plain data, percolation test exemp- Complete t o€7, it ap glace l./ . in the appropriate box; 10, 1f the info rrat act; as flood plain, elevation) does not apply, 1 11. Sign the form :o a ,j place your current address acid your certification number; 12. Make legible copies and distribute as required. ALL SOIL -PESTS MUST BE FILED WITH THE LOCAL AUTHORITY WI TH N 30 GAYS OF COMPLETION. ABBREVIATIONS FOR CERTIPIE bSOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cot) Cobble (3 - 10") SS Sandstone LS Limestone gi, - Gravel (under 3") Sand HGIf - High Groundwater cs - Coarse Sand _ perf.; ppa c€ latiQn , ate med s - Medium Sand W Well fs Fine Sand Bkjg B =i!dinq is Loarny Sand sI Sandy Loan } - Loav ,,it Slit Loant _ C Clay Loam Y I sandy Clay Loam i; sic! - Silty Clay Loam mor sc .....Sandy Clay Vn"/ with sic - Silty Clay fff _ ievv fine, faint c, C cc corni-non, coarse pt f nim - Many, rne.diurn m i .k d distinct p psonlinenl HWL - }idle ?°bftat€,r level, t,s y.r,Yf ¢.er a to €lisp' ti Btv1 ' k VRP - V rr ace point ~ y , 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. h t 0 r ~ ~y cci~e)`X yr e 1 v s _ W ~ Itl 'd (a Na lop N s •1A cwt ~ ~ v ~ 3 41 r C~ ~ d Gl\ LA _V- i# to n r h It -