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Home My WebLink About136-1031-40-110 St. Croix County Planning and Zoning Tuesday, February 14, 2006 at 3:28:15 PM Detail Sanitary Information Page I of 1 Computer 136-1031-40-110 Sub/Plat: NA Section: 28 Parcel 28.29.17.227G Lot: 1 TNIRNG: T29N R17W Municipality: Village of Hammond CSM: Vol. 06 Pg.1707 1/4114: SE 114 SW 114 Owner: Peterson, lance 1765 Cty. Rd. J Hammond, WI 54015 State Permit: 88413 Issued: 10/2011986 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permit: 0 Installed: 10/2211986 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes issuer/inspector As Built Plumber Other Requirements Additional Notes Money Owed Mary Jenkins Yes Powers, Calvin 12'x 94' bed on lot that is now within Village limits $0.00 Tom Nelson Signed Off: Yes Maintenance Scheduled Puma Date Pumped 1st Notification 2nd Notification 3rd Notification 10/2212005 - - - - - - - - - - - PETERSON, LANCE SE SW, Sect' Z8 T29N-R R• R• To of Hammond 7 Hammond, WI 54015 /q 4IJ 10-20-86 C. Powers San.Yermit#88413 Conventional, w 10 ed: 10-22986 0 i . 02/14/2006 03:21 PM Parcel 136-1031-40-110 PAGE 1 OF 1 Alt. Parcel M 28.29.17.227G 136 - VILLAGE OF HAMMOND ST. CROIX COUNTY, WISCONSIN Current rX ~I 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 - SKAALRUD, RICHARD A & LOIS M RICHARD A & LOIS M SKAALRUD 1765 CTY RD J HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1765 CTY RD J SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.786 Plat: N/A-NOT AVAILABLE SEC 28 T29N R17W SE SW 1.786 AC LOT 1 Block/Condo Bldg: CSM 6/1707 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 28-29N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 993/592 WD 07/23/1997 757/13 2005 SUMMARY Bill Fair Market Value: Assessed with: 100731 181,800 Last Changed: 10/19/2005 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.786 35,800 151,200 187,000 NO Totals for 2005: General Property 1.786 35,800 151,200 187,000 Woodland 0.000 0 0 Totals for 2004: General Property 1.786 26,900 115,200 142,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 111 Specials: Category Amount User Special Code Special Assessments Special Charges Delinquent Charges 0.00 0.00 U Total Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER.) ¢,cF_ X21 TOWNSHIP SEC. T~~N-R~W ADDRESS ST. CROIX COUNTY, WISCONSIN s W LOT LOT SIZE SUBDIVISION ~ -Fo( -6~;7nty-a C/ -~o VI'l 0 110r, PLAN VIEW. Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~'aps - 90• ~ Boo - ~9 78 S410 G~ a~ /a Jew INDICATE NORTH ARROW 4t i ~ BENCHMARK: Describe the vertical reference point used;) ss/E~ - Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer F,K cLiquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: r Tank Outlet Elevation: Number of feet from nearest Road: Front 01 Side, Rear, O feet From nearest property line Front 10 Side, Rear, O feet Number of feet from: well , building: (Include this information of the above_plot plan)( 2 reference dimensionsto septic tank) SEE ROES ~A ODE 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,() Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: a( Trench: Width: Length: Number of Lines:_ .2 Area Built:_,462,y-_ Fill depth to top of pipe: ,;j'' Number of feet from nearest property line: Front, Side, 10/ Rear,0 It. y Number of feet from well: ACV Number of feet from building: 7 (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, Q Ft. Number of feet from well: ~J Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: -~24e. License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS DIVISION LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969 MADISON, WI 53707 I~ state Plan I.D. Number: L~LONVENTIONAL ❑ALTERNATIVE O Holding Tank O In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Lance Peterson RR Hammond WI 54015 REF. PT. ELEV.: CST REF. PT. ELEV.: BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: SE SW Section 28 T29N-R17W, Town of Hammond Sanitary Permit Name of Plumber: Number: MP/MPRSW No.: County: St. Croix 88413 Cal Powers 1563 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: PROVID DLA PROVIDED LOCKINGCOV ~v(„Jlti5 l (~00 I~b 9/.2Z_ YES ❑NO ❑YES [NNO BEDDING: VENT DIA.: VENT MATL.: NUMBER OF ROAD: PROPERTY WELL: BUILDING: V NT TO FRESH HIGH W J / AIR INLET: ALARM: FEET FROM LINED ~GU V Z /V ❑YES NO C ❑YES NO NEAREST WARNING LABEL LOCKING COVER DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL. PUMP/SIPHON MANUFACTURER . PROVIDED: PROVIDED: ❑YES ONO ❑YES ONO ❑YES ONO PUMP ROILS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: AIRIINLETR H rALLONS PER CYCLE: FEET FROM LINE DIFFERENCE BETWEEN OYES OO NEAREST UMP ON AND OFF) LENGTH: DIAMETER MATERIAL AND MARKING SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) SPITS uou1D CONVENTIONAL SYSTEM: LEN TH NO. F DISTR. PIPE SP CING: COVER INSIDE DjA DEPTH WIDTH: G. A: BED/TRENCH TRENCHES: ` M ERIAL: PIT DIMENSIONS 9 f/Y" TV WELL: G: V NT TO FRESH AVEL D TH TH DISTRAL: NO. DI R. NUMBOF AIR~ILNL BELOW PIPES- ABOVE COVER. ELEV. INLET- ELEV. END ~1 PIPES' FEET FROM n/ .r t I 7 ZC NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ONO PERMANENT MARKERS EVA ONWE ILLS IL OVER TEXTURE YES NO S ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOILSODDEDSEEDEDMULCHD CENTER: EDGESOYES ONO PRESSURIZED DISTRIBUTION SYSTEM: FILL oePTH ABOVE COVER t.; WIDTH: LENGTH. TNO.OF RENCHES: HDISTR.PIPE ING. GRAVEL DEPTH BELOW PIPE, BED/TRENCH'' DIMENSIONS MANIFOLD PUMP MANIFOLD MANIFOLD MATERIAL P OESISTRDISTDISTRITION PI E MATERIAL & MARKING ELEVATION AND ELEV.: ELEV.: DIA_ DISTRIBUTION COVER MATERIAL: INFORMATION HOLE SPACING VERTICAL LIFT CORRESPONDS TO APPROVED HOL SIZE : DR ILLEDCORRECTLY PLANS. ❑YES ONO ❑YES ONO UMBE LINE: TNEAREFTF--~ COMMENTS: PERMANENT MARKERS: ION WELLS: PROPERTY EET FO^O OYES ONO ❑YES ONO b JA Sketch System on etain in county file for audit. Reverse Side. n LE. SIGNA .r' DILHR SBD 6710 (R. 01/82) [:TlffIL R SANITARY PERMIT APPLICATION COU TY In accord with ILHR 83.05, Wis. Adm. Code ST TE SANITARY PERMIT # 113 -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER W12 x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY OWNER e PROPERTY LOCATION 7p{ '/4 '/a, S , N, R 17 J~(or PRO PITY OWNER'S MAILING ADDRESS LOT N MBER BLOCK NUMBER SUBDIVI ION NAME CI , STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LA E OR LANDMARK 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) 1. a. ~ New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspectedand 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 In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X seepage Bed b. ❑ seepage Trench C. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 4_1s~ Ilene .1 Feet W Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of th private ewage system shown on the attached plans. Plumber's Name (Print): Plum s Si ature: o Sta MP/MPRSW No.: Business Phone Number: Plu er's Addr ss (Street, 'ty, State, Zip Cod21P Name of Designer: VIII. SOIL TEST INFORMATION Certi ' d S it Tester (C T) Name CST # CST' A DR SS ( reet, City, S te, Zip Code) Phone Number: C IX. COUNT/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Surcharge Fee ~U'a1t7~G~ XApproved ❑ Owner Given Initial _0 00 GI b Adverse Determination ~ &e, X. COMMENTS/REASONS FOR DISAPPROVAL: elp 4V 41 SBD-6398 (formerly 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: 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 'ocal code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; 111. 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; Vl. 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 result of over 2 years of steady negotiation and public debate. The groundwater bi11 10,roun&`; Ater included the creation of surcharges (fees) for a number of regulated practices which WiSCOfTSirl'S can effer+ groundwater. The surcharg= took effect on July 1, 1984. All of the water that i i 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 f,;nd aum nis- terec! by the Department of Natural R:~sources. These funds are used for monitori-g group J- f v,. ater, groundwater contamination ir;,.estigations and establishment of standards. arouroviate , --~W. it's worth protecting. SBD-6398 (R.03/86) • APPLICATION FOR SANITARY PERMIT S T C - 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 sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - Owner of Property Z w Location of Property, IT Section. T,429 N - R Township Mailing Address Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created No Are all corners and lot lines identifiable? Yes Yes No Is this property being developed for resale (sp,c house) ? Volume 7S" 7 and Page Number l.~ as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 1. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be ereelpful so as Certified avoid delays of the reviewing process. If the deed description Map, the the Certified Survey Map shall also be required - - _ - - - - - - - _ _ - PROPERTY OWNER CERTIFICATION 1 (We) ce&Uiy that aU Statement6 on zhi.6 ~oxm axe tjLue to the bebt of my (aura) know.Eedge; that I (we) am (axe) the owner (.6) o A the pxopeA.ty de d ch.i.bed in #h i.6 a wwtAanty deed n coxded in the 066ice ob the ~,n~axmafii,on ~oxm, by u.,tue ab and that 1 (we) County Regi6ten oA Deed6 " Vocument No. ; nm l ox 1 (we) have pxebentty awn the pxoposed Site box the Sewage poS fax the obtained an e"ement, to xun with the above de6cAi-bed pxapeaty, con t uction ob Said System, and the Same hob been duty xeeoxd,d in the 066ice o~ the County Regiztex o6 Deeds, aS Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED UZP004 CERTIFIN: SURVEY MAP CHRISTIAN AND EVAN HANSON Part of the Southeast 1/4 of the Southwest 1/4 of Section 28, Township 29 North, Range 17 West, Village of Hammond, St. Croix County, Wisconsin. UNPLA TIED LANDS OIndicates 1" x 24" iron N00,pipe weighing 1.13 lbs./ oo'oo"F zoo.oo' c W lin. ft. set. BARN `,``~~SIIt1U!/~~P X50 0IVS~ '•I J a SHED _ • - z a - LAUREN al m o" = m W M Y: Cr. 0 Q m M o f ' " m Cn ; S/ j113 13- I _ ~ RIMER ALTS,,: y+v z L a OT N N .3 I y..N Wisc.... - 0 a h 1. 786 ACRES v m O 10. N % ~IriL► ••'...•,.•t•• tQ In 77, so. rr. ~I O NET 577 ACRES ,PAI48Co LA10 P O Q W O 1~~~ V ~~11i11 ~ C 68, 709 S0. FT. O 14 J • O h ~r ZI ? h QI i ` Laurence W. Murphy Re.gistered Land Surveyor a Q3 JI C4 , O 0 SCALE /00' Y.90-00'00"C 34.79 Q N Z ^..j SOO100'00"E17.0O' O' /00' /30' M~230, O N90 00 00 E /4 h h of J to S 114 CDR. SEC. 28, T29N,R 17 u', MON.I /846.9/ 00. dT O FJ /COUNTY SURVEYOR'S N 89.51' 47 "E 2608. 01 ' . VILLAGE OF HAMMONO 33' SW CDR. SEC. 28, T29N, R /7W, UNPLA T Y E O LANDS APPROVED BY I A •G~L /COUNTY SURVEYOR'S MON.) , r. ( DATE' Description: That certain parcel of land located in the Southeast 1/4 of the Southwest 1/4 of Section 28, Township 29 North, Range 17 West, Village of Hammond, St. Croix County, Wisconsin, more fully described as follows; Commencing at the Southwest corner of said Section 28, thence N 89051'47"E (assumed bearing on the South line of the Southwest 1/4 of said Section 28) a distance of 1846.91' to the.POINT OF BEGINNING, of the parcel to be herein described; thence N 00000'00"E 389:321; thence 'N 90000'00"E 200.001; thence S 00000'00"E 388.84'; thence S 89051'47"W 200.00' on the South line of the Southwest 1/4 of said Section 28 to the POINT OF BEGINNING, containing 1.786 acres, being subject to easement over Southerly portions of said parcel for C.T.H..:'J" R.O.W. purposes as shown on this map and also being subject to easements of record. Dated: September 15. 1986 State of Wisconsin) County of Pierce) j I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Christian and EvanHanson, I have surveyed and divided the lands shown hereon in accordance with official records, Chapter 236 of the Wisconsin Statutes and the Ordinances of the Village of Hammond.; and that the map and description are a true and correct representation thereof. 1 Vol. 6 Page 1707 p'.aQ Certified Survey Maps St. Croix County, Wisconsin ~ Q Of~Q fl 0, z N H a r STC - 105 r" a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a ' H OWNER/BUYER ROUTE/BOX NUMBER Fire Number CITY/ STATE ,4,~Wyd= .Q Z IPA PROPERTY LOCATION:,&E_~G, ~ Sectio%~, T,~_,2~N, R _Z,7 W, Town of_Zi~-i•,,,1.0 St. Croix County, Subdivision Lot number • I 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 se tic tank pumper. What you pdt into f 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. acdep~ted 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 H three year expiration. £ z I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with H 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 IGNED -'()e~- ` DATE AU- 6 C~ 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. DEPA~TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 'INiDUS DUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN'RELATIONS 1 / MADISON, W1 53707 (H63.09(1) & Chapter 145.045) LOCATION: / SECT101N: ?9N1R17 V(or) n TOWNS IP/MtffdtCf'PA-CITY: LOT INI:B2LKr O.: SUBDIV SION NAME: COUNTY: NER'S UYER' NA E: MADDRESS USE DATES OBSERVATIONS MADE NO.BEDRMS: COMMERCI LDESCRIPTION: PROFIL D CR ONS: P ERCOLATION TESTS: ~I Residence ® New ~ l leplace y A RATING: S= Site suitable for system U= Site unsuitable for system O[MS [❑NAL: MMS I IN-G~ND E1 URE: S1STE - -FILLHFl-q MU K:JRECOMMEND S STEM:(optional) If Percolation Tests are NOT required DESIG RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: 3 Floodplain, indicate Floodplain elevation: 44~ PROFILE DESCRIPTIONS BORING TOTAL P H TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHM, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 9'' i e qr 9&, Z > 46, 9 - Icy / E- ,t>~.~sF G.3- 9..ttk ~cs~ 9- w,t~.r,E s B- '.127k? ?aews A" B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER WeME9 AFTERSWELLING INTERVAL-MIN. P RI 1 PERT 2 PERLOD3 PER INCH P- J,2 3 P-a P__ 30 71 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 Ris T-ii /J y 4 I t i 1 c - ! e t 1 i € E M r D I i 1 _ • 1 1, the undersigned, hereby certify that the soil tests reported on this form were ade by me in accord ith the procedures and methods specified in the Wisconsin . Administrative Code, and that the data recorded and the location of the tests are c 7We bes#pf knowledge and belief. NAME TESTS WERE COMPLETED ON: s AD SS: CERTIFICATION NUMBER: PHONE NUMBER( ptional): 1 4L Z~U~_ C2M~RE: 1. 1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-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 commercial 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 profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure 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; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 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 SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs Coarse Sand Perc - Percolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is, - Loamy Sand > - Greater Than *sl - Sandy Loam ( Less Than *1 - Loam Bn - Brown *sil - Silt Loam BI - Black si - Silt Gy - Gray *cl - Clay Loam Y Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay wi - with sic - Silty Clay fff few, fine, faint `c Clay cc - common, coarse pt Peat mm Many, medium m - Muck d - distinct p - prominent HWL - High water level, Six general soil textures surface water for liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in :ecuring a sanitary permit. The county or the Department may request verification of this soil test in the fig ld prior to permit. issuance. A complete set of plans for the private sewage system and a permit applic, i;n must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit .:ast be obtained and posted prior to tho start of any construction. ~E~iR~~~yy~i~k~ .~~N SE ~iC.✓,~C a~~~i.FD •.~/GiJ.f~ ~ 36' r r 1 J Al _ ~d~ PAGE OF CroSS Sec~Ion Ot A ~en S Ster+-~ Fresh Air Inlets And Observation Pipe ')z- C2) --Approved Vent cep Fin Mal 12` Aber. v C% J Final Or , i i 4" Cost Iron I 20- 42' About Pipe _ To Final Grade Vent Pipe Marsh Fey Or synthetic covering Min. 2" Aggregate Over Plps clatribution Pipe Too 6" Aggregate Beneath Pips ° Perforated pipe Below Complies Terminating At Bottom Of system . i ProposeD'Flnal 9rA~1{ IF-lto ~ on SOIL FILL DISTIZIBUTI01.7 PIPE APPROVED S4MHETIC COVER 'MATERIAL OR 9" OF STRAW rOFA66REGA1E OR MARSH HAy ° 1e' OF %2-21~2 AGGREGATE 8 ELEV. OFFEET DISTRIBUTION PIPE TO BE AT LEAST INCHES BELOW ORIGIIJAL GRADE AWp AT LEAST20 IAICHES BUT MO MORE THAW 42 RICHES BELOW FINIAL GRADE MAXINKMM DEPTH OF ExcAvATIop FRoM ORI&VVAL 6RAoE WILL BE IIJCNES MAMUM 9EPrH of EXCAVATION FROM 0~1141aqL 694p€ WILL BE INCHES SIGIJED: LICEMSE DUMBER: - DATE: