HomeMy WebLinkAbout231-1038-60-000
St. Croix County Planning and Zonin Friday, December 02, 2005 at 8:47.46 AM
Detail Sanitary Information Page 1 of I
Computer 231.1038.60-OW Sub/Plat: NA Section: 23
Parcel 23.30.15.693 Lot. OL 39 TN/RNG: T30N R15W
Municipality: City of Glenwood CSM: 114114: NE 114 SE 114
Owner: Booth, Marvin 1444 320th Street Glenwood City, WI 54013
State Permit: 83847 Issued: 0812711986 POWTS Dispersal: Non-plumbing Sanitation Permit: New
County Permit: 0 Installed: 10/20/1986 POWTS Detail: Trench - Seepage Bedrooms: 3 WI Fund:
POWTS Pretreatment: NA
Notes
Inspector As Built Plumber Other Reauirements Additional Notes Money Owed
Tom Nelson Yes Smith, Gale Ward 1, Outiot 39 - found original permit - Weeks $0.00
Signed Off: Yes 1000 gal. septic tank to 2 5' x 100' trenches off
former Draxler Rd. nka 320th St. Notecard
attached to archive file
Maintenance
Scheduled Pump Date Pumped 1 st Notification 2nd Notification 3rd Notification
1/1/1985 612312000 04/01/2005
6123/2003 04/0112005
10/20/1989
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
-
BOOTH, MARVIN NE SE, Section 23
T30N-R15W, t 39 I
Glenwood City, WI 54013 City of Glenwood -
Ward I
_ San.Permit#83847 8-277786_ G._Smith
Conventional, New
Vv' u~ Y'
Installed: 10-20-86
Parcel 231-1038-60-000 12/02/2005 08:42 AM
PAGE 1 OF 1
Alt. Parcel 23.30.15.693 231 - CITY OF GLENWOOD CITY
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 - JOHNSTON, JAMES H & LUCINDA S
JAMES H & LUCINDA S JOHNSTON
1444 320TH ST
GLENWOOD CITY WI 54013
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1444 320TH ST
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 14.000 Plat: 0058-OUTLOTS/ASSESSORSPLATGLENWOODCIT
O.L. 39 WARD 1 G.C. Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1179/552 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 09/21/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 1,600 244,300 245,900 NO
AGRICULTURAL G4 4.000 700 0 700 NO
AGRICULTURAL FOREST G5M 8.000 12,000 0 12,000 NO
Totals for 2005:
General Property 14.000 14,300 244,300 258,600
Woodland 0.000 0 0
Totals for 2004:
General Property 14.000 17,200 191,700 208,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 566
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 6.00
d~~fjr6 Form - S T C - 104
e AS BUILT SANITARY SYSTEM REPORT
OWNER 1~1 j V/N CDD7`'f/ TOWNSHIP lywand SEC. r7 3 T 3o N-R W
ADDRESS' ST. CROIX COUNTY, WISCONSIN
SUBDIVISION h LOT LOT SIZE -I* '4 C R e
f PLAN VIEW
Distances and dimensions to meet requirements of I•11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
PRoPe,~ ,C `w
8M /00 ' OF" N A/ L N PO PI-A AP twe e
iI A4ove f}RoyNd 11"Dr4,
/o s v G AA. Se- Rr/0_ *w ~,tl R►~t
DR I v a k h y
It-OF
vG[. .
z
rZr
87.x'7'
S~ T"oP dP i°iPe
ti
r6
0
N
f fi
INDICATE NORTH ARROW
BENCHMARK: Dgscribe the vertical reference point used /4/L jA/ fq~
Elevation of vertical reference point: ZOO f Proposed slope at site: 3P
SEPTIC TANK: Manufacturer: f Liquid Capacity:
Number of rings used: Tank manhole cover elevation: 9!1121
Tank Inlet Elevation:, fe Tank Outlet Elevation:
Number of feet from nearest Road: Front,W Side Rear, O 8a feet
• From nearest" property line Front 10SideRear, 0 D feet
Number of feet from: well building: 0
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
LIU"
Y 6
PUMP CHAMBER
Manufacturer: Liquid Capacity:
t
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank a ation:
Pump off switch elevation: Gal s.per cycle r
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest pro ty 1 Front, O Side, O Rear,0 Ft.
Number, feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length:_ /OD Number of Lines: a Area Built: O0
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, ® Rear,O Ft.~
Number of feet from well:
Number of feet from building: 36
(Include distances on plot plan).
y,
SE GE PIT
Siz Number of pits: Diameter:
Liquid d the Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box O been used o any of the above soil
absorbtion sytems? (Check ne).
HOLDING TANK
Manufacturer: acity.
Number of rings used: E1 ion of bottom of tank:
Elevation of inlet:
Number of feet from near property line: Front, O Side, Q Rear, 0Ft.
N err of feet from well:
tuber of feet from building:
ber of feet from nearest road:
Alarm Manufacturer:
Inspector: _
d O Plumber on job)
Dated : Ile
License Number:
3/84:mj
{
~EPARTME'4NT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & 34UM,AN RELATIONS SAFETY & BUILDINGS
'.O. Bb x 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
}CONVENTIONAL OALTERNATIVE slat.vlanl.D.Nvmher
❑ Holding Tank O In-Ground Pressure ❑ Mound (11 „„p ,arl)
NAME OF PERMIT MOLDER. ADDRESS OF PERMIT HOLDER,
INSPECTION DATE-
rvin Booth Rt. 2 lenwood City- WI Ol Q-' '~±3:~C)
DENG" MARK Perrnentim reference Point) DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV.: CST HEI PT. ELEV
E SE Section 23 T30N-R15W Cit of Glenwood City
lamr nl PlroMr!r. MP/MPRSW No..
Coumv$lnnarr Perron Number:
Gale Smith 5690 St. Croix 83847
EPTIC TANK/HOLDING TANK:
eANUf AC Ufl R
A LIQUID CAPACITY TANK INIETELEV. TANK OUTLET ELEV WARNING LA LOCKING COVER
O0 O ~ ^ , 9D PROVIDED- PROVIDED
'EDGING - VENT OIA. VENT MATL. t/IGH WA L V (J J1 YES ❑NO DYES
ALARM NUMBER OF ROAD: PROPERTY WELL BUILDING V NTTOFRO.H
C f FEET FROM p uN 1 LO' t O AIRINLET
DYES NO DYES
NO NEAREST ~ ~ L7
OSING CHAEH MBER:
IANUF AC TUR 9f.UU1NG L IOUII) C APAC I I Y PUM1IP MUUEI PUMP. SIPHON MANUf ACTOHEH
WARNING LABEL LOCKING COVER
DYES ❑NO PROVIOEU PROVIDED
IALLONSPERCYCLE: Pu PANOC NTROL OP RATIONAL DYES NO DYES [JNO
AFFERENCE BETWEEN NUMBER OF PItIe'f It lr Wt LI "tilt DING V NT O Itl St/
UMP ON AND OFF) FEET FROM LINE AIR INIf I
DYES ONO NEAREST 30.
)IL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing L f N441 11 IAnlf I III 'oA I I HIAI ANI
excavation. (If soil can be rolled into a wire, construction shall cease until FORCE M1IANKINI,
e soil is dry enough to continue.) MAIN
3NVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENG N NO O UISIR PIPE SPACING C V 1
S + O iNE NCHfS GI MATEgIAU
DIMENSIONS PIT INtil Ul IH.1 svllti
O LIUUH)
I uEPU/
V L ) 1 ILL UEP /1 UIS 1/ PI '1 UI TH PIPE 1ST . PI A RIAL
U)WPZP Sl 1/ ' ABOVE COVfH fltV INIII ELEV ENU NO UIS NUMBER OF PItUPtltlr WELL . HUILnIN(i VFNI fU 111E tiH
7 PIPFS FEET FROM
T L(v~ ~5
FUND SYSTEM: N
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill.material for PROVIDE A DIAGRAM OF SYSTEM
mound systems to make certain that it . ON REVERSE SIDE. SHOW ELEVA-
DYES ❑ NO meets the criteria for medium sand. TIONS MEASURED.
)ILCOVER itxtultt
ES VF NMANf D NI No MAHK'El S UIt51 HVAIH'N WI l l :]YES r) NO
VDYES ONO DYES NO
Uf PT11 OF IUPSnII tif)UUI I) SETUI II
Mlll I;HfU
D DYES ~)NO
ESSURI2ED DISTRIBUTION SYSTEM: Y
1ED/TRENCH WIDTH LFNliill NO OF LA TEHAL$PAL"N GHAVELUfPiI/NfLUWVH'1
)IMENSIONS TRENCHES f II L U 161 AHOVI (j)VI N
MANtF ULU FUW MI ULU UISTH PIPE MANII OLU MA 1,641 L NPI IHy1H InSIH Pt 1 A
.EVATION AND ELEV EL EV ulA ELEV PIPES utn
UIti Tn HliIUIN PII.1 M1PAII HinI 41AItK INrr
STRIBUTION
FORMATION HOLE Sl-'f /IOLE SPACING UHILI ED Coloff C11 Y
COVER MATERIAL VI H I If.AI I It 1;()HHf S14INl/S I11 AVP1111V1 U
PL AN%
LAMENTS: FERMAN N qqK YES ❑NO DYES ONO
OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUILDING
DYES ❑Np FEET FROM LINE
DYES ElNO NEAREST -
f
ch System on
lrseSide. R county file for audit.
SIGNATURE '
II IE
iR SOD 6710 (R, 01/82) d/'1y
sib unsconsln APPLICATION FOR SANITARY PERMIT
DILHR PL OUNTY
- OEPRRT enTOF 6.67) UNIFORM SANITARY PERMIT #
- .nouSTRV, 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'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
" MAILING ADDRESS
V I ea14- r2
PROPERTY LOCATION CITY:
1 /4 1 /4, S oZ 3 , T-70. N. R r) W N Lc, O o/ r
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms: ❑ Public (Specify):
THIS PERMIT IS FOR A:
X New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed X 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
❑ An 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 a 97
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: la =e 'p- S
N ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Fiberglass Plastic
a o
Septic Tank Capacity
Lift Pump/Siphon Chamber
Man er:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
CrD'a Private El Joint El Public
- -52 9' fiv 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: MPRSW No.: Phone Number:
Plumber's Address: Name of Designer:
0.0 C . r
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
10,~~~ ~yA ❑ Owner Given Initial
O Cs 1 pproved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
L
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
r
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - -
Owner of Property Al QOO
Location of Property -,-34, Section , T N - R W
Township ~rL etv w o o
d
Mailing Address
e Gsr d O O~ C r y 4.,
Subdivision Name IV A R Q/ -
Lot Number I?
Previous Owner of Property -_-RR ed Q~ E Y-e a ti
Total Size of Parcel A - e g e
Date Parcel was Created 9
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes _ No
Volume and Page Number as recorded with the Register of Deeds
'
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPFRTy OWNER CERTIFICATION
I (We) ce4tti.6y that aU statements on this jonm ane true to the best o6 my (oust)
knowledge; that I (we) am ( cute) the owneA (s) o6 the pno pent y des embed in this
in4o4mati,on 6onm, by vi4tue o6 a wannanty deed neconded in the 066ice of the
County RegizteA o 6 Deeds as Document No. 2 F f ► d ; and that 1 (we)
pnesentty own the pnopoaed site bon the sewage ispo.sa. -Aydtem (on I (we) have
obtained an easement, to nun with the above dedehi.bed pnopehty, bon the
eonstnuction o6 said system, and the same has been duty neconded in the 066ice
o6 the County Reg.csten og Deeds, as Document No. 3 2e rg d
'-'M NNLM4 ce- 1 8 - 69nr22e
SIGN URE OF OWNER SI ATURE OF CO-OWNER (IF APPLICABLE)
- of
DATE SIGNED DATE SIGNED
H
• C/l
ti
STC - 105 a
r
r
9
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County o
z
.,c d
OWNER/BUYER- fA/ p00 / J~ 9
H
[=1
ROUTE/BOX NUMBER .0-Y-2- Fire Number
C ITY/ STATE6:ZeNk,;00 or d 6,1-
Z IP
PROPERTY LOCATION:_&j!F 14, Section
-'2j-' T 7 N, R lam- W,
Town of ~rL~i~i~oo o/ St. Croix County,
Subdivision LcJ,~,~d l Lot number,
,
Improper use and maintenance of your septic system could reult
I
its premature failure to handle wastes. Proper maintenances con-in
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank um er. 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 ne.c-
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
O
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.
S I G N E D
DATE l1 r p~-1~ -
St. Croix County Zoning Office
P.O. Box 9$
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
Lunconwn SANITARY PERMIT
1
1 01LHR Countoy
GROUNDWATER SURCHARGE
Sanitary Permit No.
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.
Ground
SIg ure of Issuing Agent: Groundwater Fee:
"
Date: WISCO
buried'
DIIHR SSO-7289 (N. 05/84)
t ~
INDUSTRY
DEPARTMENT OF SAFETY & BUILDINGS
REPORT ON SOIL BORINGS AND
JLABOR HUMAN REDLATIONS PERCOLATION TESTS (11 DIVISION
5) P.O. BOX 7969
(H63.090) & Chapter 145.045) MADISON, WI 53707
LOCATION:- SECTION:T'
/T3o N/RjK, (or) W MUNICIPALITY; OT NO.: BL_NU. SUBDI VISION NAM
COUNTY: OWNER'S BUYER'S NAME:
1 MAILING ADDRESS:
USE
NO. BEDRMS : COMMERCIAL DESCRIPTION: DATES OBSERVAT MADE
Residence ~r
ZNew ❑Replace PROFIL CRIPTIONS:
ATION ESTS:
RATING: S= Site suitable for system U= Site unsuitable for system
IVS CONVENTIONAL: MOUND: IN-G UND-PRESSURE: SYSTEM-I -FILL HOLDING TANK: RECOM NDED SYSTEM:
(optional)
UU S❑U S❑U ❑S U S❑U vtrs aVll~~~ !
If Percolation Tests are NOT required DESIGN RATE:
under s.H63.09(51(b►, indicate: ~ If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL D P H TO 11,31F 11 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED T. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B- `
9r
B-,3 l ti~ A • -
.ate ~ S
/0o ' 1-57
B-_6-
B-
PERCOLATION TESTS
TEST DEPTH, W IN HOLE TEST TIME
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. DROP IN WATER LEVEL-INCHES
PERI D 1 RATE MINUTES
P- PERIOD 2 P PER INCH
P O U .r 'T~
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 a
of land slope.
and percent
SYSTEM ELEVATION
i - /
~02 ,rte ' ~ i
f t
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
Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
MME print
TESTS WERE COM LETED ON:
iDRESS:
CERTIFI ATI NUMBER: PHONE NUMBER (optional):
CST SIG ORE-
IBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
BD-6395 (R. 02/82)
OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 •
To be a complete and accurate soil test, your report must include:
1 , Complete legal description;
2. The use section must clearly indicate whether this.is a residence or commercial -project;
3. MAXIMUM number of bedrooms or cornmercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes, A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing uprofile descripti nsawd g to plating th prefee plla ;
7. MAKE A LEGIBLE diagram accurately locating your
separate sheet may be used if desired;
8. Make scare your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9 Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, if appropriate; lace N,A. in the appropriate box;
10, If the information (such as flood plain, elevation,) does not apply, p
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION..
ABBREVIATIONS FOR CERTIFIED SIOIL TESTERS
v
Other Symbols
Soil Separates and Textures
BR - Bedrock
st -Stone (over 1Q`") SS _ Sandstone
cal. -Cobble (3- 1Q") LS _ Limestone
gr - Grave! (under 3")
HGW - High Groundwater
*s -Sand Perc - Percolation Rate
cs Coarse Sand Well `
med s - Medium Sand W _ Bldg -Building
fs Fine Sand Greater Than -
Is -Loamy Sand ,j - Less Than
~sl Sandy Loam gn _ Brown
*I - Loam
BI Black
*sit -Silt Loam ~;y _ Gray
si - Silt
. *cl -Clay Loam Y Yellow
R _ Red
scl - Sandy Clay Loam -Mottles
sick - Silty Clay Loamt moot f _ with
sc - Sandy Clay
j
sic Silty Clay fff - few, fine, faint
-
cc common, coarse
*c°--- Clay.- ,
' rnm Many, medium
pt`-- Peat d -distinct ,
m Muck p - prominent
HWL - High water level,
\ surface water
Six general soil textures BM _ Bench Mark
for liquid waste disposal
VRP - Vertical Reference Point
t
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.. /
10 .18
1<y
9
Smith Plumbing &Heating PHONE (715) 265-4838
N ~a0~ GLENWOOD CITY, WISCONSIN 54013
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