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Parcel 032-1027-95-100 03/10/2009 04:34 PM
PAGE 1 OF 1
Alt. Parcel 10.31.19.134B 032 - TOWN OF SOMERSET
Current 0 ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - THOLE, MICHAEL S & CHRISTINE S
MICHAEL S & CHRISTINE S THOLE
2263 50TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2263 50TH ST
SC 4165 OSCEOLA
SP 1700 WITC
Legal Description: Acres: 5.920 Plat: N/A-NOT AVAILABLE
SEC 10 T31N R1 9W SW SW 5.92ACRES LOT 1 Block/Condo Bldg:
CSM 7/2001
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
10-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/03/2001 650095 1673/167 WD
07/23/1997 908/308
2009 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/03/2008
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.920 75,100 86,000 161,100 NO
Totals for 2009:
General Property 5.920 75,100 86,000 161,100
Woodland 0.000 0 0
Totals for 2008:
General Property 5.920 75,100 86,000 161,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 11/08/2005 Batch 05-50
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
f
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' Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1~ 7C~ h I °n TOWNSHIP LC~_&,4Aa~ SEC. /0 T 3 1 N-R jj_W
ADDRESS SDa~'1 e$ 1 ST. CROIX COUNTY, WISCONSIN
SUBDIVISION J1~ LOT LOT SIZE / v
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83 r"-
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM zz ,mac
°
1
Cllr b t-,r
14f
`1,
3
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
r a-u
Elevation of vertical reference point:
10 Proposed slope at site:
SEPTIC TANK: Manufacturer: %1S Liquid Capacity:
Number of rings used: Tank manhole cover elevation: a a 5
Tank Inlet Elevation: 7~O Q 5/3
Tank Outlet Elevation: ~
Number of feet from nearest Road: Front, Side, Rear
O a feet
From nearest property line Front, Side,ORear,0 ( feet
Number of feet from: well
building:
ng: ~
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
A44 4
PUMP CHAMBER
Manufacturer: Liquid Capacity:
z
/7~•P
pump Model: Pump/Siphon Manufacturer: c JL Pump Size Y.
83 ~L g
Bottom of tank elevation:
Elevation of inlet: -26
Pump off switch elevation: ~s Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type: f~
T Q ~
Number of feet from nearest property line: Front, 0Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building: (O
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
• Sd6
Width: Length: /D(,~ Number of 'Lines: Z Area Built: .
Fill depth to top of pipe: 0 O
Number of feet from nearest property line: Front, Side, O Rear,0 Ft 15-;?~,
Number of feet from well: _ eP
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT /
Size: umber of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Bu' .
Has eith a drop box O or distribution box O been used on any of the above soil
absor tion sytems? (Check one).
DING TANK
Manufacturer: Capacity:
Number of rings sed• Elevation of bottom of tank:
Elevation of 'nlet:
Number of eet 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 j b:
License Number: ~J T
3/84:mj
1
PUMP CHAMBER
Manufacturer: IN ~t6 K-S Liquid Capacity:
Pump Model: W('' I Pump/Siphon Manufacturer: arl et 1d Pump Size Y &f
Elevation of inlet: 83 g
?A Bottom of tank elevation: 73Z
Pump off switch elevation: ~s Gallons per cycle: /aZ a l~-
Alarm Manufacturer:' Alarm Switch Type:YAJAAAI
i
Number of feet from nearest property line: Front, Side, O Rear , Ft.;~O
Number of feet from well:
Number of feet from building:. ~p
(Include distances on plot plan). .
SOIL ABSORPTION SYSTEM
Bed: Trench:
r
Width: Length: /D Number of Lines: Area Built: Jc~C~
Fill depth to top of pipe: O
r
Number of feet from nearest property line: Front,'
Side, O Rear,O Ft oR~
110
Number of feet from well: (p 7
Number of feet from building: o?~~YLIA0tz-sLy-
(Include distances on plot plan).
SEEPAGE PIT Z'
Size: umber of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Bu
Zeh drop box O or distribution box O been used on any of the above soil
ytems? (Check one) .
Manufacturer: Capacity:
Number of rings sed: Elevation of bottom of tank:
Elevation of 'nlet:
Number of eet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector.
Dated: Plumber on b: O
License Number:
//J~~
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O.6*bX 796L* PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
91CONVENTIONAL ❑ALTERNATIVE StatePlenLD.Number.
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound IIf assigned)
ADDRESS OF PERMIT HOLDER: IIE
A. Schie4etbe in R NSPEC710N DAT
rNameof PERMIT HOLDER:
RK (Permanent roint , DESCRIBE FROM•PLgN' Samers e wI 54025
w, Section 10, T31N-R19wTawn a~ Samerse REF. PT. ELEV CST REF P ELEV
mberMP/MPRSW No. ly Steed Sanitary Permit Number
3254 S cuix 83770
SEPTIC TANK/HOLDING TANK:
MANUFACTURER;
W LIQUID CAPACIT V: TANK INLET ELEV.. TANK OUTLET E EV WARNING LABEL
DED ER
t&o ~•fr%"~ l''Jp '7 ~Q PROVIDED: PH LOCK
V `f v OVIDED:
BEDDING: V.. VENTMATE IZZ GWATEH V PR KJYES ❑NO ❑YES i;aNO
M NU MBER OF ROAD- PROPERTY WELL. BUILDING. VENT TO FRESH
DOSING S CHAMBERFEET FROM /7/ LINE AIR INLET.
C ' ❑YES NO NEAREST- 12-1 Z_
:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMPVIOL L
PUMP,SIPHON MANUFn'TIIREH
It WARNING LABEL LOCKING COVER
❑YES .0 W ' I PROVIDED PROVIDED
GAL DNS PER CYCLE: PYES ❑NO YES ❑NO
(DIFFERENCE BETWEEN q NUMBER OF 'HOPEHTY WELL BUILDwG VENT TO FRESH
PUMP ON AND OFF) NFEET EARESTOM uNE- /50 Ala INLET -
SOIL ABSORPTION SYSTEM. heck the soil moisture at thee d pth of plowin~ NO - `v
or excavation. (If soil can be rolled into a wire, construction shall cease untgl FORCE METE Et MATE RInE AND MAE7K IN
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM: v
BED/TRENCH WIDTH. LENGTH NO OF 'IS"' PIPE SPACING COVER
DIMENSIONS THENES j MnTERInL PIT NSIDE DIn =PITS LIQUID
DEPTH
H A ''*El I)FPTI' FILL D H UISTH PIPE UISTH PIPE DISTR. PIPE MATERIAL
B ".,E LOW PIPES if ABO ECOVER EI EV. INLE t ELEV END NO OISTIi PIPES NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
r 9 FEET FROM LINE ✓ AIR INLET:
2" 7 2 Z NEAREST---W,
MOUND SYSTEM: Z - !aq
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑ YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE
PE HMANI NT MAHKE HS OBSERVATION WELLS
DEPTH ovER TRENCH eED DEPTH ovFR TRENCH BEU
CENTER EDGES UEP TH OF TOPSOIL ❑YES ❑NO ❑YES ❑ NO
S()UOFU SEE DEU
MULCHED
❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH ENGTH NO OF LA7EHALSPACIN(i GRAVEL DEPTH BELOW PIPE
TRENCHES: FILL DEPTH ABOVE COVER
DIMENSIONS
ANIFOLD F
ELEV
M PU M P MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO UISTH DISTR. PIPE UISTHIBUTION PIPE MATERIAL $ MARKING
LJ DWI-AA ELEV PIPES
ELEVATION AND ELEV
UTA
DISTRIBUTION
INFORMATION DOLE SIZE HOLE SPACING DHILLEO COHRECT I Y
COVER MATE HIAL VE R7ICAL LIFT CORRESPONDS TO gppROVED
PLANS
COMMENTS: ❑YES ❑NO ❑YES
PERMANENT MARKERS: OBSERVATION WELLS.
NUMBER OF PROPERTY WELL ❑NO
BUILDING:
FEET FROM LINE:
100
YES ❑NO ❑YES ❑r,
R
NEAEST-
- - RE -
1
Z, 6
Sketch System on
Reverse Side. I In c y file for audit.
GNATURE
T17LE
DILHR SBD 6710 (R. 01/82)
77 wisconsin APPLICATION FOR SANITARY PERMIT
C C~
DILHR COUNTY
- OEPFigTfTIEnTOF (PLB 67) '
ommw~ InOUSTRY, LRBOR& HUTgn gELRTlOnS UNIFORM SANITARY PERMIT #
?3'770
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
' ` £ MAI (ADDRESS
PROPERTY OCATION G Cfi+.V-
1/4 1/4, S D , T41, N, R vi+6644@ E:
lI K.,) W TOWN OF: B
LOT UMBER BLOC NUMBER SUBDIVISION NAME NEARE A LAKE OR LANDMARK
STATE PL N I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: . ❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ 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 {,Seepage Trench IJ Seepage Pit
~ System-In-Fill ❑ Holding Tank
❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit #
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions, issued
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity Q O
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
rIFTHIS cturer:
IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound
In-Ground Pressure
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
ptc Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
mss 4,f 6- Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installati of the private sewage system shown on the attached plans.
Na f Plumbe (Print): III Signature:
MP PRSc~W Phone Number:
Plu ber's A dress: Ol TTT~~~ G 7 ( ~s 1F(v-~
Name of Designer:
to .
CS; hpr,-Ax
COUNTY/DEPARTMENT USE ONLY
Signature Issuing A nt: Fee:
Date:
/ ❑ Disapproved
❑ Owner Given Initial
Reason f Dis ppro al: C/ Approved Adverse Determination
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.) ;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent &sposal 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.
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PUMP CHAMBER CROSS SE&ION 'ARID SPECIFICATIONS
VENT GAP
N"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
L5' FROM DOOR. JUNCTION BOX MANHOLE COVER
WINDOW OR FRESH IY"MIU. V'
AIR INTAKE GRADE
~ y"MIN.
coNDUaT
18"MIN.
IAJLE T 'PROVIDE I
AIRTIGHT SEAL I i 1 1 ~,Jrc.f P
APPROVED JOINT A I III hp t APPROVED JOINTS
W/C.I. PIPE I III W/C.I. PIPE
EXTENDING 3' I 11 ALARM EXTENOING 3'
ONTO SOLID SOIL B I I ( ONTO SOLID SOIL
I
C I I ON
ELEV./ F? PUMP
~ OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TAWK MANUFACTURER HAS SUCH APPROVAL3,•APPRo1/Ep
86Dp rl Nf4
SEPTIC E SPECIFICATIONS
DOSE
TANKS MANUFACTURER: NUMBER OF DOSES: PER DAy
TAAJK 51ZE: GALLOWS DOSE VOLUME
ALARM MANUFACTURER: pfy) x,, -4- INCLUDING BACKFLOW: gel (,ALLONS
MODEL NUM9ER:
CAPACITIES: A= L INCHES OR 'Z-114GALLONS
SWITCH TYPE: +f~( :~,d
B = INCHES OR ' GALLO►A~~Sg
PUMP MANUFACTURER: !
C IIJCHES OR 14ALLOI.1'S
MODEL NUMBER: ' CO --H~3885 D=/.km'_INCHES OR 2Col GALLONS
SWITCH TYPE: V )4'r 0I 4 NOTE: PUMP AND ALARM ARE TO OE
MINIMUM DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUITS
.C,
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE. FEET
+ MII~~UI,,MUM NETWORK SUPPLY PRESSURE. . FEET 2 Z" Z~~ FjKi~~v7
+ L,~ FEET OF FORCE MAIN X 196 F>//ooFTFRICTIOU FACTOR..FEET
lex )z a
TOTAL Dy1JAMIC. HEAD FEET ` 1' f 7
/ .
INTERNAL DIMLIJSIOMS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH ~f
SIGNED: LICENSE HUMBER; ~3ZS'SL DATE:
WIRING OF SEPTIC PUMP CHAMBEKS * 4
Weather-proof Wiring EncYo.,sur4,
Approved '
Locking Cover and Disconnect Means OutsiAe of
and Within 3 Feet of Chamber
NEC 410-57(b); ILHR 16.19(2)&(3)
Enclosure may be mounted on a post
T Seal Conduit
Grade Min.. 4" Opening _J Conduit Required
ILHR 16.19(2)(b) NEC 300-5(d); ILHR 16.190)(c)
Manhole
Riser 12" Min. NEC 300-5(a) Ex. No. 4
Separate Pump and Alarm
Circuits ILHR 16.19 (1)(a)
and (b)
A
CONDUIT' NEC 300-5(d) CONDUCTORS: NEC 310-7
1. Rigid Metal Conduit 1. OF or USE Cables
2. Rigid Non-metal Conduit 2. Conductors in Approved Conduit
3. Intermediate Metal Conduit
(no EMT conduit)
Pump Circuit -
Alarm Circuit -
Weather-proof Enclosure
ON/OFF
Control
Circuit
Wire l~'~" \lNr
Nut Wire
Nut
i
i
I Bushing to i Enclosed
Protect Receptacle I
Wires NEC 300-15 (a)
I NEC 300-5(h) 1
l ~
* After Edward Lawry, DILHR Chief Electrical Inspector
Not recommended because of possible interchanging of pump & Alarm Plugs.
The neutral conductor shall not be common to both pump and alarm circuits
as per ILHR 16.19(1)(d).
NEC - National Electrical Code
ILHR - Industry, Labor and Human Relations
Wisconsin Administrative Code
2/86
00
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SEPTIC TANK MAINTENANCE AGREEMENT ryi
St. Croix County z
d
9
OWNER/BUYER
t~
ROUTE/BOX NUMBER Fire Number
.CITY/STATE
Ti~~ Z I P pZ c~
PROPERTY LOCATION:' , 34, Section T_ / N, R/,47_W,
Town of St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior-to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. y
0
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.
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-
Performance Submersible Effluent
Curves Pumps
METERS FEET
90
MODEL 3885
25 SIZE 3/4" Solids
C WE15H
70
= 20 WE10H
J
H 60
WE07H
15 50
WE05H
40
10 WE03
30 t
20 E03L
S
Pu W1 10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
I 1 1 I
0 10 20 30 m'/h
CAPACITY
~GOULDS PUMPS. INC.
SEPECA FALLS NEW YORK 13148
METERS FEET
120 MODEL 3885
35 110 WE15HH SIZE 3/4n Solids
30 100
90
25
70
X 20
J
F 60
0
H
11H
15 50
40
10
20
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
0 10
20 30 ml/h
CAPACITY
01985 Goulds Pumps, Inc.
ElfectiveJuly_ scat
APPLICATION. ITARY PERMIT
{
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property dt/ __-'k, Section h) T_fZ&N-R W
Township
Mailing Address
Address of Site
Subdivision Name
Lot Number
Previous Owner of Property R
Total Size of Parcel
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 as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warrant Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) eenti6y that a.te statements on this 6o4m tike cue to the best ob m
knowledge; that 1 (we) am (cute) the owner(s) ob the pnopWy de6c&ibedin t )
his
.in6aunati.on 6ohm, by vi tue o6 a wantcanty deed tecmded in the 046.ice o6 the
County Reg"teh ob Deedsas Document No. 719 and that I (We) pne~sentty
own the ptopos ed .6 to bon the sewage d",35-6 s yd em (on I (we) have obtained an
easement, to nun with the above de-6c ibed ptopenty, 6o& the con6tAuction o6 .said
system, and the .tame has been dut recorded in the 046.ice o6 the County Register o6
Deeds, ad Document No.
A 19
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNE DATE SIGNED
I
i
L
L '
DEPAR.TMENT'OF REPORT ON SOIL B
INDUSTRY, ORINGS AND 3~ SAFETY & BUILDINGS
LDINGS
• HUMAN RELATIONS PERCOLATION TESTS 115
P.O. BOX 7969
(H63.090) & Chapter 145.045) MADISON, WI 53707
12!4 SECTION: 1
r3 W TOSHIPPd}TY: : BLK. NO.UBDSION NAME:
"T! I A)
OWNER' BUYE MAILING ADDR ESS
USE E I 46
r NO, BEDRMS, : COMMERCIAL DESCRIPTION: DATES OB ERVATIONS MADE
Bence ❑New place PROFILE DESCRIPTIONS: PER OEATIO N TESTS:
L5~ zi -fir
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PR
~ ~ URE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
IC~`J U 0 S( IJ EIS
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
••,L Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BOR I N TOTAL
NUMBER nFCru inl ELEVATION D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR TEXTURE, AND DEPTH
OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B_ 1 $75
> L7 0 .4
13-3
B-
B_
13-
PERCOLATION TESTS "N
TEST DEPTH, W IN HOLE
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. MDROP IN WATER LEVEL-INC.
PERIOD 1 PERIOD 2 RATE MINUTES
P- PER PER INCH
P- \
P-_ J
-
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-
of land slope.
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
SYSTEM ELEVATION ,5
i
xv-
I
asp .4
f
ti
x
b
_ tN
3
6-
Pit
3
t
( 1~
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and
U
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
ds specified
~i the sin
NAME (print):
j TESTS WERE COMPLETED ON:f
ADDRES
8 CERTIFICATION NUMBER: R: PHONE NUMBER (optional):
CST SIG E;
LDISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82)
-OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - S - 6395
To be c i to soil test, your report Must incluc:le:
1. Gorr- : ect;
2. The use indicate whether this is a residence or corn - 4
3, MAX(M> 3orns or commercial use planned;
4. Is thi a system; DING TAII' 4 l i= ALL
5, c 1 )01 e r
r s plot plan;
c
7 s ,_.eferrecE A
nd are permanent;
ercolation test exemp-
be appropriate box;
11. T PL FILED WITH THE
` .r T
„ATI ` ,E`ER°, t, -OIL S
~ .ter
rned S
fs
is
*zbi
~rrri
oani
sc - C'',y Loam
sic - am
5 - ,
Si
;nca Point
TOT"
. tr,e C~°r° neat may request
fi r of s zr the private
in order to
r ct' n e