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HomeMy WebLinkAbout030-1015-40-008 0 O m e d Lo~ c to CD o gt _D 1 I d ; V` 3 rt ~ n y N (n 0 ~ y II iv ~ r-I ~'S S p W O CO CD Cl ~Ow N N O D C A ° (D ° a ~ it v co cn ` 1\ 8 Z Q v A o m = ro a o 3 N y' I = W O Gt CD W _(1y o CD a O. C c II ~`j D cQ N 7 Q c C O O pdj = 3 rn A I O 8 j m Ar co co n_0i II o r N ai rn rn c I 3 v O O O Cl) • .0 _ OIQ ca tnui~, ~ v CD I3 a v v v, d O p' N CD » N j 'I 7 O 0 " m m 0 w N DC o I O O a 7 N • (D , @ m N N (D = CD CD W (D 3 --4 Cl) Z o I A Z m o in c I ; n' a I 3 v 0 I cNo W CD M z 3 3 N Z CD A A ~ C O Q c fD N ~ 2)(0 0 -n O O N O N N N O II N I Q v CD S r., o ~k O N 0 V (D ft A CD • 04/15/2005 03:34 PM Parcel 030-1015-40-00$ PAGE 1 OF 1 030 - TOWN OF SAINT JOSEPH Alt. Parcel 04.29.19.64J ST. CROIX COUNTY, WISCONSIN Current X# Permit # Permit Type Creation Date Historical Date Map # Sales Area Application 00 0 Owner(s): * = Current Owner Tax Address: * MILLER, SCOTT H & LYNDA A SCOTT H & LYNDA A MILLER 1163 SUNDANCE PASS HUDSON WI 54016 * =Primary Districts: SC = School SP = Special Property Address(es): * 1163 SUNDANCE PASS Type Dist # Description SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.140 Plat: 0333-CSM 05/1478 SEC 4 T29N R1 9W SW NW LOT 12 CSM 5/1478 Block/Condo Bldg: LOT 12 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 04-29N-19W Parcel History: Notes: Date Doc # Vol/Page TWD 08/29/2002 688711 1963/268 07/23/1997 2004 SUMMARY Bill M Fair Market Value: Assessed with: 4824 342,000 Last Changed: 07/07/2004 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.140 77,200 259,300 336,500 NO Totals for 2004: 3.140 77,200 259,300 336,500 General Property 0 0 Woodland 0.000 Totals for 2003: 3.140 45,300 186,400 231,700 General Property 0.000 0 0 Woodland Lottery Credit: Claim Count: 1 Certification Date: Batch 102 Specials: Category Amount User Special Code Special Assessments Special Charges Delinquent Charges 00 0.00 0.00 Total Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT 2? OWNER TOWNSHIP SEC. TN-RW ADDRESS ST. CROIX COUNTY, WISCONSIN -ZZL SUBDIVISION, r~ LOT - LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4507 n 91,67 01` 70' INDICATE NORTH ARROW Z __j BENCHMARK: Describe the vertical reference point used Allx,Z,,, his Elevation of vertical reference point: ~29,e~ Proposed slope at site: SEPTIC TANK: Manufacturer: a'-'e-'Liquid Capacity: S22 Q'A Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: q2 7 Tank Outlet Elevation: Number of feet from nearest Road: Front, Side 0 Rear, O feet From nearest property line Front 10 Side, Rear, O / feet Number of feet from: well A114y- ;lot (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER s ,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: ;ly Trench: Width:-- L2 Len the Number of Lines:- Area Built -:2 422- Fill depth to top of pipe: ~ Number of feet from nearest property line: Front, O Side, 0 Rear,0 Ft. Number of feet from well: 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: Dated: Plumber on job: `J License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.Q. BOX 7469 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number. ' Holding Tank ❑ In-Ground Pressure ❑ Mound (1f assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER- INSPECTION DATE David Pearson Rt. 2, Hudson, WI 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: IcST REF. PT. ELEV.: SW NW Section 4, T 29N-R19W, Town of St. Joseph,Lot#12, Sundance Pass Name of Plumber: MP/MPRSW No.. County Sanitary Permit Number: Cal Powers Jr. 1563 St. Croix 79130 SEPTIC TANK/HOLDING TANK: ci. r, MANUFACTURER;- eLIO D CAPACITY: TANK I LET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER t~.. PROV DED: PROVIDED. it • YES ONO DYES ONO BEDDING: VENT DIA.: VENT MATL: HIGH WAT R NUMBER OF ROAD: PROPERT WELL : BUILDING: VENT TO FRESH ALARM. FEET FROM YES ONO DYES ONO NEAREST leo ~D ~jC CJ 01 il! DOSING CHAMBER: MANUFACTURER . BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO DYES ONO GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE' IAIR INLET: PUMP ON AND OFF) OYES ONO INEAREST-~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 111,-T11 DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH. IND. OF DISTR. PIPE SP CING. COVER INSIDE DIA.. #PITS. LIQUID BED/TRENCH 4p TRENC S, TRIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DIST PIPE DISTR. PIPE DISTR. PIPE MATERIAL. N IsTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABO COVER. E V INLET. EL V. END: I s FEET FROM LINE ';'L. AIR INLET: • e ? NEAREST-so O L Y4 7 1,//j 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 TEXTURE PERMANENT MARKERS JOBSERVATION WELLS DYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED :]DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED: CENTER- EDGES: DYES ONO OYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV.: DIA.. ELEV.: PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: El YES El NO ED YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIG AT R TITLE: h DILHR SBD 6710 (R.01/82) wls~onsln APPLICATION FOR SANITARY PERMIT Q, COUNTY DILHR (PLB 67) UNIFORM SANITARY PERMIT # - OEPRRTTEnT OF InOUSTRY. LRBOR & Hum1 n RELRTIOn. -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 1 PROP RTY OWNER MAI NG ADDRESS PROPERTY LOCATION TY: .;r-- ,C (Or) VII TOWN OF: 1/4 A1/4, S , N, R &i (or) LOT NUMBER BLOCK UMBER SUBDIVIS N NAME NEAREST R , LAK R LANDMARK STATE PLAN I.D. NUMBER YPE OF BUILDING OR USE SERVED T X 1 or 2 Family Number of Bedrooms: Public (Specify): / THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair ll Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. XSeepage 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 ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Y 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): q~~Ie Z Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation o t rivate sewage system shown on the attached plans. Na of lumber (P ' Sig at e• MP/MPRSW No.: Phone Number: (7i PAddress: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved waia gx~2~ ❑ Owner Given Initial O~ ~7 O(O Approved Adverse Determination Reason for Di p 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 • A 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. .'L 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/contracGQ]~,("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 (Da u; d s psaineo Rmrsor) Location of Property 5LJ NU) 3y, Section - , T a4 N - R q W Township S-~ • , 05,e:ph Mailing Address R4• r3- ~.-N~u~son ~,u c 5' O I L Subdivision Name 5urdame, Po.,-,s Lot Number )off Previous Owner of Property mfr. QiS2N~ Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes T~ No Volume 7and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. 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. PROPERTV OWNER CERTIFICATION 1 (We) ceAt~6y that aPt atatemen-ta on this 6oAm ate true to the but ob my (ouA) h.nowtedge; that I (we) am (aAe) the owneA1,6) o6 the pnopehty debcA bed in this in6o4mation 6o4m, by v. 4tue of a wak4anty d ed Aecoa.ded in the Ojjice of the County RegizteA o6 Deeds as Document No. ; and that 1 (we) pAesentty own the pupobed site 6oA the .aewage poaaLFsyatem (on 1 (we) have obtained an easement, to Aun with the above descAibed pnopeaty, JoA the con t&uct%oY. o6 a aid .b ystem, and the dame hab been duty AecoAded in the 06 6 i,ce o6 the County . RegizteA o6 Deeda, a6 Document No. ) . SIGNATURE (W OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED 1. WISCONSIN REAL ESTATE TRANSFER RETURN Wisconsin Department of Kevenue GRANTOR: GRANTEE: Name v Lf , Y~ f k Name i Social Security Number 3' ?{ii l! c Social Security Number Full Address - New address if property transferred was residence Full Address anti trl' 2 Is grantor related to grantee? Relationship includes, ❑ Yes' [No Name and address to which tax bills should be sent if not the same as above marriage, blood relative, partner, lessee-lessor, co-owner, parent corporation or joint owner. `If yes, explain how related Grantor is ❑ Individual ❑ Partnership ❑ Corporation ❑ Other Grantee is ❑ Individual ❑ Partnership ❑ Corporation ❑ Other Telephone: Grantor( ) - Telephone: Grantee ( ) - PART I - PROPERTY TRANSFERRED PART II - PHYSICAL DESCRIPTION AND INTENDED USE Check proper box and enter name of municipality and county 1. Kind of Property 2. Principal IntendedUse ❑ City ❑ Village 9 Town g ';-4 -1 i) 5 o," a. Land Only a. RResidential d. ❑ Agricultural County 2; C' J t x r ❑ New Construction b. ❑ Commercial e. E1 Recreational Street address of property transferred. Include road name and /or fire number. ❑ Building Previously Used c. E1 Industrial f. ❑ Other _ El Solar Design 3. Land Area and Type Estimated r? 1:: 1,•+ Y' * ;_'.t 5 5 ❑ Earth Sheltered Home a. Lot size x ❑ Legal Description (Fill in complete legal description in space below or if metes ❑ Condominium b. = IQ Total Acres ❑ and bounds description attach 4 copies of it as shown on the instrument of ❑ Time Share 1. Tillable Acres ❑ conveyance. If certified survey map number is used in description list town, b. Residential Units, if any 2. W.T.L. Acres ❑ range, section and acres.) Tax Parcel Number 1-• 0 19 One Family 3. F.C. Acres ❑ i Lot No. 4-, Blk No. Section Town Range ❑ 2 and 3 units 4. Managed F.L. ❑ Plat Name wr ` 'f A v 4 py ❑ 4 or more units c. Ft. of Water Frontage ❑ 5"41 L PART III - FINANCE Is Agricultural property transferred? Yes No if yes complete Financial Terms (PE-500 Supplement) on last page. PART IV - TRANSFER (One answer is mandatory for questions 1-4, 5a or b must be completed, questions 6, 7 & 8 as apply) f 1. R Sale 2. ❑ Gift 3. ❑ Exchange 4. ❑ Other transfer (Explain) 5. Ownership interest transferred a. GkFull b. E1 Other (Explain) i 6. ❑ Deed in satisfaction of land contract - What was the date of the original land contract? 1 7 Amount of mortgage assumed by grantee? $ 8. Does the grantor retain any of the following rights: E] Life estate El Easement PART V - ENERGY Is this property subject to the Rental Weatherization Standards, ILHR 67? ❑ YES ❑ NO If NO, enter Exclusion Code from instructions NOTE: If YES attach the appropriate DILHR Transfer Authorization form (Cert. of Compliance, Stipulation or Waiver) to be recorded. PART VI - COMPUTATION OF FEE OR STATEMENT OF EXEMPTION (See instructions) 1. Total value of REAL ESTATE transferred (purchase price, etc. rounded to next even hundred). Include real estate exempt from _ j local property tax (Solar, wind, M&E etc.), but exclude personal property $ 1 2. Value of personal property transferred but excluded from line 1 $ ` 3. Value of property exempt from local property tax included on line 1 $ 4. TRANSFER EXEMPTION NUMBER if exempt for Reasons 1-16 (see instructions) Sec. 77.25. 4 A 1 i i 5 Fee - thirty cents per one hundred dollars of value (line 1 times.003) Make check payable to Register of Deeds $ 3 ' PART VII - CERTIFICATION The transfer must be reported regardless of the grantor's state of residence. Information on this return will be used to administer Wisconsin's Income and Fran- chise Tax Laws, Real Estate Transfer Laws, Renta[Unit Energy Efficiency Laws and General Property Tax Laws. j We declare under penalty of law, that this return (Including any accompanying schedule) has been examined by us and to the best of our knowledge and ` belief it is true, correct and complete. Signature of Grantor or Agent Date Print or Type Agent's Name SIGN x,;, i HERE Signature of Grantee or-Agent Date Print or Type Agent's Name f If Signed By Agent Agent Address Phone - i i Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance Conv. Code LEAVE 7 411 `R ::f THIS Parcel Number 19 19 Code: County Tax District Assm't Dist AREA L L BLANK I I 1 Office 2 Field 3 Use 4 Reject I A B C D E F T T Ratio Consideration { School District No. PE-500 (R. 11-85) H z H . a ST C- 105 r r ' a H SEPTIC TANK MAINTENANCE AGREEMENT H 0 St. Croix County z d a H OWNER/BUYER DCLu,d P eavsan ROUTE/BOX NUMBER iL Fire Number .CITY/STATE n lt7lSC ZIP 5U(Lo PROPERTY LOCATION: SW) Section 4 T N, RW, <wnSin;P . Town of Av.Ac-o" St. Croix County, • ~OS~pFI Subdivision 5),Kn80:ham , Qass Lot number /02 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 U) 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 Cl_nA. a? 1 SIo 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. ° to r = m m m j w -2 2 N3 m v u;w~ O OCD A <o r 9 O A O ~ o ~ a3 'o; w :co0,21 O cww~~ ~ c Z ' 'a 0 (D 'C3 a CD N p? w O I c CD o ap0 w '010, 0 v m;0, ID aN -,im :3 ((D =:R - ~ , r to CD ? OM C>D' '00 A3a 0COD w M, nr- s - 0 :E i w O_ O L C R C N Zc c<Qn a O ww? ~~mw ~wCD o~oac~DO D < ~y Er co QO A - G. -o W ° 0 W ma a- Q va o y rc ? o lu C U' m f `n ) ~y 4 W ' Z D m in0~~~ Z am A 3 (D m cD ?a n 0 co w a N M a ~w ~o m a m0?acow CA ='-1 o a a o w O C ITi C s o aT M y? o~ 0 m _ w O 0 3 -i ti --,o o yc c 0 r-9 MR 0 Si ~ aof wcccfw m w aaCLIm 0 _o cD a cr N=."I ,~~w=Cw ~.w0 °C to CDD0 g'~n M A C 7 ~n 3 A (D O , g 0.0 o to CO) CL C CD m CL 0 acD 0 O 3 vi c l. 0 < \ e► Q o - z y O C • DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTFjY, G DIVISION BOX LABOR NDLATIONS PERCOLATION TESTS (115) MADISON WI 7969 HUMAN RE (H63.090) & Chapter 145.045) LOCAATI N:A)l SEC % N/R/ (or TOWNSHIP/ In NICIPALITY: LOTNO.:BLK. O.:SUBDIVISION NAME: J ' C UNTY: OWNER'S/BUYER'S NAME: ING ADDRESS: d USE DATES OBSERVATIONS MADE NO. BE RMS.: COMMERCI L DESCRIPTION: [Z PRO ILE DESCRIPTIONS: PER O ATION TESTS: W Residence t ~l New ❑ Replace 2a r~ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTE -I -FILLHOLDING TANK: RECOMMENDED SYSTEM:( tional) I MS ❑u OS ❑u ZS ❑u ❑ s Au ❑ s Zu I 4A If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING I TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IA, ELEVATIOND OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- / 7 sf - -e- A B3 - > - B- B- B- PERCOLATION TESTS r TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER W16H£b`` AFTERSWELLING INTERVAL-MIN. PERT 1 PERIO 2 PERI PER INCH P- rr 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 i's,` f1 m E a><~~ i i 71- .3/ I I _ l F ~ I r z s E f r ~ F E E ; l , e , Leo k '"41 $'a t i ~ ~ F I 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. NAM rin : TESTS RE COMPLETED ON: 7~1/' - - 56: ADD S: CERTIFICATION NUMBER: PHONE NUMBER (optional): C IG ATU E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER - v • A INSTRUCTIONS FOR COQ I-, LE-71 Ii' G FORM 115 - SB - 6595 T- hP 1 complete and accurate soil test, 1clude: 1 1-91 dec,rii 2 ct' m rT st tl 5 a ni or commercial . JVf number c f e -er( ; 4 a new or repla( 5 suit-1W A c.`rE IS el E FOD -11NIG TANK ONLY IF ALL YF 1; A IT C 5 E completing e 7, scale is pre 1- 10, I )X; ' - D ITH THE r, r -OR CERTI j f s Y Y C} P1 TO THE r it may ri i Est -)r th- in i - =moll DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION,Iy~ SECTION: TOWNSFi/tP/Mt1+E}PfkttT/Y: LOT NO.:BLK. NO.: SUBDIVISION NAME: 1 /T-71 N/R4 y k4or) W T f7 `f 7 A41 ,V~ COU~T OW S /BUYER'S NA E: AILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: n PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence '0 New ❑Replace y_Z RATING: S= Site suitable for system U= Site unsuitable for system ! f CONVENTIONAL: MOUND: IN-GROUND PRESSURE:SYSTEM-IN-FILLHOLDINGTANK: RECOMMENDED SYSTEM: (optional) BS ❑U ,©S DU ❑U 0 S EISmell If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: Impf 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.) 3 .S z s B- 8 %Z NL 7~i ~j -Z-4- Brr, d - B-3 , 7 15120 '5 83 I _13 B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- P- P_ T P-_ 1 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 17 i T j 1 i ~1+ i J ZQC1 3 low E E E i 0 'I 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: ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER (optional): CST SIG TU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R• 02/82) - OVER - INSTRUCTIONS OR COMPL`°°r - I- 115 - SB - 6395 To h P a cm-nn' urate soil test, your report i ~r this is :e ore r t; 3 : e 4. TANK ONLY IF Al L. e_ 7. 10 3^ THE "'FI SOIL TESL-tea w T' T, t _t I r ' ~~i/J J-"t ~sc~l 006 ~~3' G ro a Ito, /411 30-) 49 a ~ Q ►lk PAGE OF C j Fresh Air Inlets And Observation Pipe ~.d SC9~ 4 Approved Vent Cap Minimum 12" Above Final Grade t 20- 42" Above Pipe _ 4" Cost Iron To Final Grade Vent Pipe Marsh Hoy Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution -Tee Pipe -0 0 0 0 0 i Be Aggregate Be 0 Pertmoled PIPa Below o Coupling Terminating At Bottom Of System I P~UPOSen t trial 9rad< SOIL FILL DISTRIBUTIOf.I PIPE APPROVED S4kiIETIC COVER 2"oFA6GREGATE ~'`MATERI^I OR 9" OF STRAW OR MARSH HAy (o0F%2-zi/Z AGGREGATE ELEV. OF FEET, I DISTRIBUTI0M PIPE TO BF' AT LEAST( INCHES BELOW ORIGINAL GRADE AMU AT LEAST20 INCHES BUT MO MORE THAN 42 INCHES BELOW FINAL GRADE MAXIMUM ®&QTH OF EXe-AVAT160 FK014 OWIMAL 6RADE WILL BE L_ INCHES MINIMUM 9f r}t OF EXCAdATI®N FROM. 00,141NAL 69 4PE WILL BE INCHES ' i SIGHED: LICENSE NUMBER: DAT E