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Parcel 020-1083-70-000 05/23/2005 03:34 PM
PAGE 1 OF 1
Alt. Parcel 29.29.19.335132 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
WAYNE J & DIANNE H JOHNSTON JOHNSTON, WAYNE J & DIANNE H
409 DEER HAVEN DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 409 DEER HAVEN DR N
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE
SEC 29 T29N R19W NW SW LOT 2 C.S.M. Block/Condo Bldg:
V4/1116
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 745/59
07/23/1997 721/461
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 40,000 164,800 204,800 NO
Totals for 2005:
General Property 2.000 40,000 164,800 204,800
Woodland 0.000 0 0
Totals for 2004:
General Property 2.000 40,000 164,800 204,800
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
Parcel 020-1083-60-000 05/23/2005 03:35 PM
PAGE 1 OF 1
Alt. Parcel M 29.29.19.335B 020 - TOWN OF HUDSON
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
" LEE, ELWYN & CATHERINE
ELWYN & CATHERINE LEE
403 DEER HAVEN DR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 403 DEER HAVEN DR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.001 Plat: N/A-NOT AVAILABLE
SEC 29 T29N R19W NW SW LOT 1 OF C.S.M. Block/Condo Bldg:
4/1116 EXC PARCEL 335F
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 718/513
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.001 46,000 175,100 221,100 NO
Totals for 2005:
General Property 3.001 46,000 175,100 221,100
Woodland 0.000 0 0
Totals for 2004:
General Property 3.001 46,000 175,100 221,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 311
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 5 j(J~~ TOWNSHIP SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
w h R0/1 D
1
9y% , 19,X5
3):
je0o
Y3-
"8
9
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used O&AI Algyr C,, ijo, ,
Elevation of vertical reference point: Proposed slope at site:
~h
SEPTIC TANK: Manufacturer: 0>AEE'z Liquid Capacity: /Qe1
Number of rings used: % Tank manhole cover elevation: f~%',4C>
Tank Inlet Elevation: r Tank Outlet Elevation: ICJ;
Number of feet from nearest Road: Front, Side, Rear, 0` ~y feet
From nearest property line Front, 0SideWRear,0 feet
Number of feet from: well ~building: 21
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
p Model: Pump/Siphon Manufacturer: P ize
Elevatio f inlet: Bottom of tank elevat•
Pump off switch a ation: Gal per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from neare proper line: Front, O Side, 0 Rear Ft. _
umber of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
~(D
_.7
Width: Length: Number of Lines;_ Area Built:-
Fill depth to top of pipe: L112
Number of feet from nearest property line: Front, 0 Side, O Rear,O Ft.1 Z
Number of feet from well: 10 IV
Number of feet from building: /07
(Include distances on plot plan).
AGE PIT
Si Number of pits: Diameter:
Liquid dept Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or di ibution box O been used on any the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: acit
Number of rings used: E ation of bottom o nk:
Elevation of inlet:
Number of feet from n est property line: Front, O Side, O r, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
z e,
Dated: Plumber on job:
License Number: 3 S
3/84:mj
DEPAFITVENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.p. BOX 7969
BUREAU OF PLUMBING
MADISON, WI 53707
CONVENTIONAL DALTERNATIVE Some Plan l.D Number
,rN IH assrgnenl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION 11`KTE
Wayne Johnston 107 7th, Hudson' w1 54016 BENCH MARK (Permanent reference you IT DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF PT. ELEV
Sw SW., Section 29, T29N-R19w, Town a4 Hudson
N.,,m. no Plumber. IMPIMPFES"' No.. C.. n, S-o t.,v Perron Number
Donavan Schmitt 3205 St. Cuix 83809
SEPTIC TANK/HOLDING TANK: . :
MANUFACTURER LIQUID CA AC TY TANK INLET ELEV, TANK OUTLET ELEV WARNING LABEL LOCKING COVEN
/J~p l PROV DED PROVIDED
BEDDING NT OIA. VENT MATL.. HIGH WATE A ~ YES ❑ NO k-fYES D NO
NUMBER OF ROAD. PROPERT WELL BUILDING. VENT 70 FRESH
ALARM
FEET FROM ~J LINE J / 7 AIR INLET
YES ONO DYES ONO NEAREST )Ilb / CQ/ . 71
DOSING CHAMBER:
MANUFACTURER BEDDING JLIQUID CAPACITY PUMP MODEL PUMP. SIPHON MANUF ACTURLH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED
DYES ONO DYES ONO DYES CJNO
GALLONS PER CYCLE: P LIMP AND CONTROLS OPERATIONAL. NUMBER OF PHOPF if TY JWF LI. HUII DIN(, VENT TO FHE Sol
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLFT
PUMP ON AND OFF) OYES ONO NEAREST 10
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LF NnTH nlnntF TF 11 vnn THAI AND nInRKIN(,
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH No OF I ISTR PIPE SPACING COVER 1INS151 UL1 -pi IS LH)UID
/ THE NC HE MATERIAL' PIT I)EPII1
DIMENSIONS
(,HAVEL DEPTH FILL DEPTH I)ISTH PIPE DISTN PIPE DISTR. PIPE MATERIAL O H NUMBER OF PHOPEHTY WELL HUI LOING VEN1 TO fltf SH
1Hf LOW PIPES 4NOVE CDVER F I I F T 11N. V EPIP S LINE AIR' TO i
/ - FEET FRO
14~1 M
~f
A9 00.• f1 LJ NEAREST-s- Q Q Z,
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-
DYES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TE x TUNE PFHMANI NT MAHKf HS OWM HVA I ION WE I I S
LINO
CDEEPNTTHER OVER THE NCI( HFU DE VTR OVF H TRENCH BED DEPTH OF TOPSOIL_ S(11)DF I) DYES I EF OID ONO - DYES M11(1L (:RI I)
EDGES _ C-~YES ONO DYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATE HAL SPACIII N(; (iHA VEL DF PTR Hf LOW PIPE F It L DEPTH ABOVE LOVE H
TRENCHES
DIMENSIONS
Pl1
MANIFOLD MP MANY 0LD DISTR. PIPE MANIF OLD MATERIAL ND DISiH
ELEVATION AND I:ISiIi PIPE 1)ISlli if4llllflN PlPI M1IA TI HIAI &MAIIK IN,,
ELEV. ELEV. CIA ELEV. PIPES UTA.
DISTRIBUTION
INFORMATION ROLE SIZE HOLE SPACING FF ILLLD (.()H{IF =ATEHIAL VF I+TR At I. 11 -T( ORHF SPONDS IO APPHOVI D
PLANS
OYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBEROF PROPERTY WELL BUILDING
FEET FROM LINE'
DYES ONO DYES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SI 'NAT RE TITLE
DILHR SBD 6710 (R. 01/82) I~
=6aff3_ SANITARY PERMIT APPLICATION couw;Y
LNR In accord with ILHR 83.05, Wis. Adm. Code SaTAT~ESANITARYPERMrr#
_
I& ? 3 310 C?
-AttaeW6omplete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
,C- O & '/4,5W %4, S J_ Ta , N, R E (orj~D
PROPERTY WNER'S MAILING ADDRESS LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME
CITY, STATE ZIP CODE PHONE NUMBER El VCITY ILLAGE : NEAREST ROAD, LAKE OR LANDMARK
1 Q i S' _7 M To C Q+R.MleAt -4-A
11. TYPE OF BUILDING OR USE SERVED: . (JaU
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. N 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 inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. X Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. E1 Mound f. ❑ IGP
. In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. X Seepage Bed b. ❑ See a e Trench C. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): p
3 CA Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strCucted Steel glass Plastic App
Tanks Tanks
Septic Tank or Holdin Tank X 0 ❑ ❑ ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumbe 's Signature: (No Stamps) M PRSW Business Phone Number:
ill'Al &/v
lumber's dress (Street, City, State, Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST #
CST's ADDRESS (Street, City, State, Zip Code) Phone Number:
At. ) if!
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surgharge Fee
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
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 gvery ZJp>3,years;
6. If you have questions concerning your private sewage syste contact your local code adrriinistrator 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: li 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;
lll. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all 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'/2 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) brother 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 biii Groundwater
included the creation of surcharges (fees) for a number of regulated practices which Wiscori~ws
can effect groundwater. The surcharge took effect on July 1, 1984, Ali of the water that burlE J e-asare
is used in your building is returned to the groundwater through your soil absorp#+. ~n
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 rr onitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
,,BD-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 is
sold and submitted to this office with the appropriate deed recording.
Owner of Property
Location of Property N~ Sr W 3L, Section T '60~q N - R_ W
Township A S D N w
11
Mailing Address 3 010Sd00 WtsO r Hods L
Subdivision Name $ 0 S S T -
Lot Number
Previous Owner of Property
Total Size of Parcel fJ~G
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number It 0p 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.
PROPERTY OWNER CERTIFICATION
I (toe) ceAt,c 6y that aU statement/s on this joAm aAe tAue to the best ob my (out)
knowtedge; that I (we) am ( ate ) the owneA (s) o6 the pAo peh ty des cA bed in thus
.i.n6onmation {oAm, by vivrtue o6 a wakAanty deed AecoAded in the 066.tce ob the
County Regiztet o~ Deed6 as Document No. Ll 37. 1 r ; and that 1 (we)
p4aent2y own the pno pos ed e.i to 6 oA the .6ewag e d c-d pops of sy.6tem (o& I (we) have
obtained an easement, to Aun with the above descAi.bed ptopenty, 6oA the
conht&uct%on o6 said system, and the same has been duty Aecotded in the Obgice
o6 the County Regtisten o6 Deeds, ass Document No.
to aw-ft-
SI NA URE OF ER q~ SIGNATURE OF CO-OWNER (IF APPLICABLE)
G`
DAT IGNED DATE SIGNED
• z
En
H
^ a
STC-105
a
SEPTIC TANK MAINTENANCE AGREEMENT ~y+
St. Croix County z
r t7
a
OWNER/ BUYER tV A Y10 L U M
ROUTE/BOX NUMBER J 3 ?j Fire Number
,CITY/ STATE ~-~0 O SD W f $ G - ZIP g ae ~v
PROPERTY LOCATION: New , S1W t4, Section a- , T;~-? N, R W,
Town of t+0 0 Sy' dD , St. Croix County,
Subdivision PF-P-KIgjt soeuc / 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 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. y
0
E
I/WE, the undersigned, have read the above requirements and agree
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,
LABOR AND • P.O. BOX 7969
PERCOLATION TESTS 1151 DIVISION
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045) MADISON, WI 53707
jC5 TION: S SECTION: TOWNSH P/AJ~bTY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
'/a 0~/ Td~/N/R R(ar►W
TYWNE R'SUYERS NA MAILING A DRESS: WA~v n iE , - - 1Z 4~ -1.0 7 i
USE
DATES O E V TIONS MADE
NO. BEDRMS.: COMME IAL DESCRIPTION:
esidence EJWew El PROFILE DESC RIPTIONS:ER OLATION TESTS:
Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOmUND: IN-GR~OUNQDPRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENE
D SYSTEM: (optional)
J SJ S Jc--iv El U ~ S Q
C~ J
If Percolation Tests are NOT required DESIGN RATE:
under s.H63.09(5)(b), indicate: If any portion of the tested area is in the
Floodplain, indicate Floodplain elevation:
C I PROFILE DESCRIPTIONS _
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- > a5 as
1547
B- 2, oo ~ ~ Ada sO //7 = -
B- 3
r7 r2
C. 9,qr
B_
PERCOLATION TESTS
I TEST DEPTH WATER FN TESTTIME NUMBER INCH S FTERSWELOLING INTERVAL-MIN. MIN. DROP IN WATER LEVEL-INCHES
PERIOD t RATE MINUTES
PERIOD 2 PERI D PER INCH
P-
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
_
~V Y r i I [
3i
19.E n ~r
F E
i
I
E
,
E
F ,
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:s
A
C;;Iel FN
j CERTIFICATION NUMBER: PHONE NUMBER (optional):
-7 C1 90
CST SIGNA R
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
i
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To' cornplete and accurate soa +est, your report Must include:
1, - ~g-31 description;
2, m must clearly it its is a residence or cornmer
urnber of bedroom or A-3 planned;
4 or replacement system;
ie suitabil rating boxes A "TPPI,E FOR A F" nING TAIL ALL
'TPAS V" PULED OUT "L 'ONDITIOI`
ati ns shown he -escripti( s and completing t ( n;
7 am accurately I locations. swing to scale k A
8. IV town, and a! it;
. Cot sx _ as e , r -ercolation test exernp-
ti
7C hood plain, elevation) d )propriate box;
1. y r Current address ar__r y
ld cop;r, -istribute as reyuir-,L _ ST JST RE FILED WITH THE
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