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Parcel 038-1163-20-000 02/06/2006 02:46 PM
PAGE 1 OF 1
Alt. Parcel 30.31.18.766 038 - TOWN OF STAR PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
EDWARD JR,& M SCHNITZLER FAZEKAS O - FAZEKAS, EDWARD JR,& M SCHNITZLER
1958 RIVER VIEW LA
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): • = Primary
Type Dist # Description * 1958 RIVER VIEW LA
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 2.520 Plat: 0227-CRESTVIEW ADD
SEC 30 T31 N R1 8W LOT 2 OF CRESTVIEW ADD. Block/Condo Bldg: LOT 02
EXC AS DESC IN 1117/063
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
30-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1117/63 QC
07/23/1997 845/433
07/23/1997 775/234
07/23/1997 762/204
2005 SUMMARY Bill Fair Market Value: Assessed with:
120007 268,000
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.520 34,600 228,800 263,400 NO
Totals for 2005:
General Property 2.520 34,600 228,800 263,400
Woodland 0.000 0 0
Totals for 2004:
General Property 2.520 34,600 228,800 263,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
• Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP = SEC. T N-R W
ADDRESS 14A ST. CROIX COUNTY, WISCONSIN
A~A) Xk~6,240 1JJ',5::&17
SUBDIVISION ~1Jt~dT(~i6eFJ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
63 . c Jr.P v :3 SS - Q~ CSy
0" j. 9 9-1, 7
SGi 9~ 99
tl~ e
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: 161.t Proposed slope at site:
SEPTIC TANK: Manufacturer.rf j ...r, ~ t Liquid Capacity: /&*9' ag `
Number of rings used: Tank manhole cover elevation: 9/os'
Tank Inlet Elevation:-V_ Tank Outlet Elevation: -.9Q ~7
Number of feet from nearest Road: Front, Side, Rear, O
feet
From nearest property line Front,OSide,ORear,(;~ ,r~_ feet
Number of feet from: well , building: J~
(Include this information of th above plot plan)( 2 reference dimensions to septic tank)
_ CRP DFVRDCV CTTNV
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:
Ft.
Number of feet from nearest property line: Front, O Side, O Rear
0
Number of feet from well:
Number of feet from building:
=czj~cb
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: V Trench:
Width' Length y Number of Lines: r_~2_ Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft.
Number of feet from well: 'dw--
Number of feet from building: - 'rl
(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:' lv Plumber on job:
License Number :
3/84:mj
pEPARTMENT Of INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
OCONVENTIONAL DALTERNATIVE State Planl.D.Numb
er:
❑ Holding Tank D In-Ground Pressure ❑ Mound (lf assigned)
NAME OF PERMIT HOLpER: ADDRESS OF PERMIT LDER: t INSPECTION DATE:
BENCH AR, (Permanent reference point) DESCRIBE IF DIFFERENT FROM LAN: v
REF. PT. ELEV.: CST REF. PT. ELEV.:
S 3 o o~I- ig 21 eua644,
d~
1
Name of Plum sec 9 MP/MPRS No.: County: Sanitary Permit Number:
f I « 1 J'
SEPTIC TANK/ DING TANK: ,Q S
MANUFACTURER: LIQUI CAP TANK INLE LEY.: TANK OUTLET ELEV.. WARNINGED LABEL
LOCVKING COVER
PROVID: PROIDED:
BEDDING: VENT IA.: VENT MATL.: HIGH WATER /y YES ONO DYES ONO
fL ALARM: NUMBER OF ROAD: PROPERTY WELL: BUILDING: JVENT TO FRESH
I -I I) FEET FROM LINE:' D AIR INLET:
YES ONO CIYES ONO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: JPUMFMODEL. JPUMP/SIPHON MANUFACTURER.
- WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
YES ONO DYES ONO OYES ONO
GALLONS LE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE CE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH 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:
BED/TRENCH WIDTH: LENGTH TR ENO.OF NCHES DISTR. PIPE SPACING COVER INSIDE CIA #PITS LIOUID
DIMENSIONS MATERIAL: PIT DEPTH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. P ATERIAL: NO. DISTR. NUMBER OF
BELOW PIPES . ABOVE COVER . ELEV. INLET ELEV. END: I ,e PROPERTY WE BUILDING : V NT TO FRESH
/ PIPE~j /FEET FROM LINE AIR INLET
OV NEAREST-
MOUND SYSTEM: 0
Mound site plowed perpendicular to slope
and furrows thrown Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
YES NO meets the criteria for medium sand. TIONS MEASURED.
D O
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DYES ONO OYES ONO
CENTER. EDGES DEPTH OF TOPSOIL: SODDED SEEDED MULCHED.
:
DYES ONO DYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH: TRWO. -OF ENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD
PUMP MANIFOLD DISTR. PIPE M IFOL AT RIAL. NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
V,: ELEV.: DIA.: ELEV.: r PIPES. DA:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER gTE L
/M spy/q VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
.
: PERMANEgrr 1OYES NO V DYES ONO
COMMENTS OBSERVATIO S: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
YES ONO NEAREST
T1' t
Sketch System on
Reverse Side. n county file for audit.
TITLE:
DILHR SBD 6710 (R. 01/82) -
SANITARY PERMIT APPLICATION
{Z, CO Y
•DILHR In accord with ILHR 83.05, Wis. Adm. Code 5r
STATE SANITARY PERMIT #
.5
-Attach complete 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
PRQPERTY OWNER
;~~11 Al~s PROPERTY LOCATION
'/4, S 0 T , N, R E (or)(D
PROPS WNER'S MAILING ADDRESS OT NUMBER BLOCK,NUMBER SUBDIVISION NAME
ITY, STATE ZIP CODE PHONE NUMBER ❑ CITY NEAREST ROAD, AKE OR LANDMARK
IV TOWNO
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 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. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. X Seepage Bed b. ❑ seepage 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):
Feet Private El Joint ❑ Public
Aq-
VI. TANK CAPACITY in gallons Total of Manufacturer's Name Prefab. Site Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete glass App.
p.
Tanks Tanks structed
Septic Tank or Holding Tank app ❑ 1:1 ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instal latio pr'vate s age system shown on the attached plans.
Plumber's Name Print): P tiSt MP/MPRSW No.: Business Phone Number:
~~l Ino i
Plu er's Addre s (Street, City, State, Zip Code):, Name of Desig r:
~
-7 OL
VIII. SOIL TEST INFORMATION
Certified Soil Tester CST) Name CST # -
~J
CST's ADDRESS ( treet, City, ate, Zip Code) Phone Number:
4d 14
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing A nature (N p
Approved ❑ Owner Given Initial Surchar a Fee f b
[7XCj1_1
'
Adverse Determination f`~-- /
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"autholity. Anew 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 bepumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
If. 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;
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'/z 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 bill Groundwater
included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's a
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Leasure
is used in your building is returned tv the groundwater through your soil absorption o
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 Rosources. These funds are used for monitoring ground- p T
~
v aim=, rr^.~r ±water contamination investigations and est blishment of standards Groundwater,
is wcrtl: protecting.
`BD-6398 (R.03/86)
H
N
STC - 105 r
r
a
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County O
z
d
OWNER/BUYER a
ROUTE/BOX NUMBER Fire Number
CITY/STATE
~ s u s Z I P S^YO / ~7
PROPERTY LOCATION:, Section T3e-:) N, R
l S 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- I
sists of pumping out the septic tank every three years or sooner, i
if needed, by a licensed septic tank um er. What you put into I
the system can affect the function of the septic tank as a treat-
ment stage in the wast.e 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.
_ H
O
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 Ii
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.
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 jV0FS1,py Lle Aloll
Location of Property 3% Section 3 y , T 3/ N - R 1.9 W
f9wnship
Mailing Address Wo,a/e
-e ts -,e
Subdivision Name e s*, P /y dN` for
Lot Number
Previous Owner of Property I-e-rle - A&-Irl/
Total Size of Parcel fg~i Ickes
Date Parcel was Created ~I~•c.~ 19gG
Are all corners and lot lines identifiable? x - Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume NO /Z and Page Number O el 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.
PROPERTy OWNER CERTIFICATION
1 (We) cexti6y that atZt statements on this foam ane true to the beat ob my (ouA)
knowledge; that 1 (we) am (ane) the owner. (s) o6 the pnopen ty des cA bed in this
inbo,%mation boAm, by viAtue ob a wa Aanty deed neconded in the Obbice ob the
76; and that I (we)
County Regis eh o6 Deeds as Document No.
X/ 2,
pnebentty own the puposed site bon the sewage disposat system (on I (we) have
obtained an easement, to hun with the above descAibed pnopen ty, bon the
con tAucti.on ob said system, and the same had been duty recorded in the Obbice
ob the C u y Re listen ob Deeds, as Document No.
SIGNATURE OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
3
DEPARTMENT REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
tJVDUSTRY, - DIVISION
LABOR
HUMAN NDLATIONS PERCOLATION TESTS (115) MADISON W 7969
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP /M ITY: OT NO.:BLK. O.: SUBDIVISION NAME:
1/45,1/4 /T N/R i (pr ; r
C NTY: OW ER'S BUYER'S N ME: AILING ADDRESS:
I S/ &'611
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: ICOMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: WResidence LENew ❑Replace _
RATING: S= Site suitable for system U= Site unsuitable for system
RESE-N-TIONALou: M®ND: IN-GR~OU~ RE: SYSTEM-I -FILLHO❑LDING~N :RECOMMENDED Y TEM:(optional)
If Percolation Tests are NOT require DESIGN ATE: ZJ If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Ctrl, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- nJ 1JErlSt S
~LZ Z11
6- >
s-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER mel ES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER 3 PER INCH
P_
P- r s
P- 'T'- S'S- AhQAZ~4 210
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.
141
SYSTEM ELEVATION
14~ xu~E~~D ! _
E
,
~ r
E
T 1
E I 1 i E~
t
E
1
I `
~ F
I, the undersigned, hereby certify that the soil tests reported on this form were made by mein accord with the procedures and methods specified in the isconsin
Adrr4ini'strative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NA (print): / TESTS WERE COMPLETED ON:
C
A D ESS:r CERTIFICATION NUMB HONE NUMBER (optional):
C N RE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner end Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To - and accurate sail test, your report most include:
1. C.. description;
2, Tl- se section must clearly indicate whether this is a r sidence :ect;
3. MAXIMUM numb ,drooms or commercial t;
4. Is this a ne system;
6. Corr-l «F, rig boxes. A SITE IS L.DING TANK ONLY IF ALL.
U` , LED OUT BASED C
6, is shown here for writinc• i nd completing the plot plan;
:urately locating your test ` vying to scale is preferred. A
iced;
_ertir.Jl r )wry, and are permanent;
9. <as as to dat I colation test exemp-
in, in tl box;
Y ar addr
as i THE
r 30 GAYS 0
IATIONS FOR CERTIFIED SOIL. TESTERS
Seri
aged s
f
is - - Than
Br -
BI
si Cy f
_ Y aw
R
o n-,
c
pt
M
H~ `L -
} i
T~ B
t I y i `ijueSt
fnr private
der' to
t
DEPARTMENT REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, - DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUMAN RELATIONS
N WI 53707
(H63.09(1) & Chapter 145.045)
LO ATION: , SECTION: TOWNS HIP/N%J+*£tl`*LITY: LOT NO.:BLK. O.: SUBDIVISION NAME:
_~AW PA
COUNTY: OWNER'S/BUYER' NAME:
MAI N ADDRESS:
USE s DATES OBSERVATIONS MADE
NO. BEDRMS.]COMMERCI ADESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
R_ XNew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system _ `L `TA CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM- N-FIL HOLDING K: RE OMM NDED
SYSTE ptiohaf)
S DU Ql S ❑U S DU ❑ S ®U EIS ®U
F ercolation Tests are NOT requr DESIGN RATE: If an
y portion of the tested area is in the
er s.H63.09(5)(b), indicate: 7 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH tN. OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 414& Z
B-
B- > Q -
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER -144eHM' AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER D PER INCH
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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
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I, the undersigned, hereby certify that the soil tests reported on this for 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 j (print): TESTS WERE COMPLETED ON:
-
CERTIFICATION NUMBER: PH
A ONE NUMBER optional):
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DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
I
I 1 TI NS FO.. PLETING FORD 115 R SBD - 6395
To c cf- ar°rurate soil test, repo,'t Most include:
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PAGE OF
Crr)SS S~cll01"1 p~ ~t ~c~ S Y 5
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Fresh Air Inlets And Obeervallon Pipe
C Approved Vent Cap
Minimum 12" Above -
Final Grade
20- 12" Above Pipe _ 4* Cost Iron
To Final Grada Vent Pipe
tderM Flay Or Synlhelk Covering
win 2" Aggregate
Over Plpe
Dlelributlon
Pipe o 0 0 -Too
6' Aggregole o
Beneath Pipe PerlarairJ Pipe Saizw
o Coupling Terminating At
Bottom 01 System
PruPoSeU~t+'In'`I19rh~1{ ~
L~~tJwT ►o~l
SOIL FILL
DISTRIBUTIOI4.I PIPE
-7 APPROVED S4M1ETIC COVER
L MATF.RjAI- OR 9" OF STRAW
OF AGOREWE
OR MARSH HAy
t6LEV. OFFEET (e OF 12-z i/2 AGGREGATE o8
2zQ , tM&L
a
DISTRIF5UTION PIPE TO BE AT LEAST IIJCHES BELOW ORIGIIJAL GRADE
A1JU AT LEASTZO IAICHEs BUT 1.10 MORE THAM 42- IAICNES BELOW FIIJAL GRADE
MAXIMUM DI:Qr11 OF EXCAVATIOP FKOM bKI&*JA . &RAoE WILL BE IUCHEs
MINIMUM gEpr" OF EXCAVATION fR0M'oIKI(,1WAL GROE WILL BE INCHES
SIGLIED:
LICEMSE IJUMBER:
' DATE:; Zj~ gl~