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PAGE 1 OF 1
Alt. Parcel 33.29.19.802 020 - 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): O = Current Owner, C = Current Co-Owner
O - BOUCHIE, RICHARD D & JUDY
RICHARD D & JUDY BOUCHIE
604 COUNTRYSIDE LA
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 604 COUNTRYSIDE LN
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.730 Plat: 0215-COUNTRYSIDE VILLAGE
SEC 33 T29N R19W COUNTRYSIDE ADD LOT 16 Block/Condo Bldg: LOT 16
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/03/2000 625793 1524/09 WD
07/23/1997 707/168
2005 SUMMARY Bill Fair Market Value: Assessed with:
92670 248,300
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.730 77,900 175,300 253,200 NO 05
Totals for 2005:
General Property 2.730 77,900 175,300 253,200
Woodland 0.000 0 0
Totals for 2004:
General Property 2.730 33,700 139,200 172,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 110
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
c ~
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Fj?ffrj L L eZ0,,_cj TOWNSHIP ~y~ U~ SEC. 3 T 2 9 N-R W
ADDRESS VC#50fl ST. CROIX COUNTY, WISCONSIN
L./ "~s C Cr)Sbin
SUBDIVISION C(Darr)' LOT 1 LOT SIZE
V1 fl"etvp_
PLAN VIEW
Distances and dimensions to meet requirements of I•LI1R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Q; b r
IND CATE FORTH ARROW
~LX
BENCHMARK: Describe the vertical reference point used 01e--_
i
Elevation of vertical reference point: /d a Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity: It) 00 `4.
Number of rings used: '2-~ Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
r
Number of feet from nearest Road: Front,( Side,O Rear, O Ya feet
`C`J r
From nearest property line Front,0 Side,0 Rear, O 13 3 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
`I
PUMP CHAMBER r
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
s
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: C i tiZTrench
Width: J A Length: Number of Lines: - Area Built: i
Fill depth to top of pipe: t
Number of feet from nearest property line: Front, O Side, Q Rear,O Ft.
Number of feet from well: / cu p-
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: t
License Number:
3/84:mj
DEFARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS f PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7965'^ BUREAU OF PLUMBING
MADic30N, WI 53707
bCONVENTIONAL OALTERNATIVE State Plan l).D. Number.
El Holding Tank El In-Ground Pressure ❑ Mound (lf assigned
NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER: INSPECTION DATE
Frank Leonard R. R., Hudson, WI 54016 /1 0
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. IT. ELEV.
SE SE, Sec. 37, T29N-R19W, Town of Hudson, Lot#16, Countryside Village
Name of Plumber: MP/MPRSW No. County Sanitary Permit Number:
Cal Powers 1563 St. Croix 58947
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
OYES ONO OYES ONO
BEDDING: VENT DI7 VENT MATL. HIGH WATER rAREST
MBER OF ROAD: PROPERTY WELLBUILDINGJVENTTOFRESH
ALARM ET FROM LINEAIR I"LET
OYES ONO OYES ONO DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING ELLABE:L LOCKING COVER
PROVIDEPROVIDED:
OYES ONO OYEYO
OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WE LL IL
DING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE IAIR INLET
PUMP ON AND OFF) EYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing It FNGTH 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 NO OF IDISTR PIPE SPACING COVER NSIOE DIA -PITS LIQUID
DEPTH
DIMENSIONS Z 5 L TRENCHES MATERIAL. PIT
[;RAVEL DEPTH FILL DEPTH DISTR. PIP DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER I PROPERTY WELL. BUILDING. VENT TO FRESH
BELOW PIPES ABOVE COVER. ELEV. INI-T ELEV. END. PIPES FEET FROM i LINE: AIR INLET.
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
OYES ONO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
OYES NO OYES NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED)
_ I J
DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
OYES ONO OYES ENO EYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.. DIA.. ELEV.. PIPES. DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
OYES ONO OYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
I ~ OYES ONO OYES ONO NEAREST
~ I 0
1
Sketch System on Retai n county file for audit.
Reverse Side.
SIGNAT TITLE.
DILHR SBD 6710 (R. 01/82)
Tconsln APPLICATION FOR SANITARY PERMIT
D 1 L H R COUNTY
DERRRTmenTOF (PLB 67) UNIFORM SANITARY PERMIT #
- InDUSTRV, LRBOR 6 HumAn RELRTIons
-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
PROPERTY OWNER MAlt ADDRESS
r.
FI, f4 Y- 11 , ~ 7, :t (J ,C )I S
L
PROPERTY LOCATION G}--TY:
c V44A=A G F :
1/4 !:1/4, S , T2` N, R a ~'(or) W TOWN OF: r'4 T
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STAT B7N I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms:
~ ❑ Public (Specify): THIS PERMIT IS FOR A:
N 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.
X Seepage 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
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
r
Manufacturer: " r_-~
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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
i
Name of Plumber (Print): sign ture 7 /MPRSW No.: Phone Number
Plumber's Address: y /J Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
Lts' ❑ Owner Given Initial
fyC )o~r GFGPJ 4:7 Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
r
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 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.
1
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
r
Owner of Property
Location of Property ~L i- ''4 ~L , Section i , T 1- N- R W
.
Township ~JJ<
Mailing Address t it t~ 7 So
Subdivision Name
i
Lot Number
Previous Owner of Property 4i"V+11C~
Total Size of Parcel 2
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
1
Volume and 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.
PROPERTy OWNER CERTIFICATION
I (We) eenti. y that ate statement/5 on this {onm ahe tAue to the best o~ my (ouh)
knowledge; that I (we) am (ane ) the owne t (.5 )._o_{_the _ pn.o petet y dens cAi.b ed in t6w5
inAonmati.on ~onm, by vilLtue oA a waithgntg--deed seconded- ' the 0AAice ob the
County RegisteA oA Deed/s " Document QVo. _ aid that 1 (we)
peelsently own the pnopopsed site Aon the ewuge Apo-ate,sy/stem (on I (we) have
obtained an e"ement, to nun with the above de_16mcbed p,,Lopent:y, {ion. the
eon,sthucti,on o{ said /sy/stem, and the tame hays been duly Aeeonded in the O~6ice
ob the. County Registers o{ Deeds, as Document No. )
SI ATURE OF 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
107
Walter J Gregory, Registered Countryside Village.
Land Surveyor, Dated June 20, 1979.
Revised None Shown.
-to- Rec. Sept. 24, 1979.
In 114", page 69, #359993•
The Public.
SURVEYORtS CERTIFICATE--Dated June 20, 1979.
I, Walter J. Gregory, Registered Land Surveyor, hereby certify,
that I have surveyed, divided and mapped Countryside Village, located
in the SE,-~ of SE,i-, and NEu of SE4 of Section 33,, and NW! of SW4 of
Section 34-29-19, Town of Hudson, St. Croix County, Wisconsin, Des-
cribed as follows: Beginning at the SE corner of said Section 33'
thence S 89°55119 % (true bearing) 1319.01t; thence NO°03134"W 1344.6 1;
thence N 0°04102"E 1313.231; thence S89029t50"E 377.001; thence 589°
28150"E 332 571''thence S 0°25112"W 428.oot; thence S89°5lt33"E 599.1 t;
thence S0°25'12?'W 400.481 along the W right-of-way line of Gilbert
Road, thence sly 181.201 along said W right-of-way line of a 333.00,
radius curve concave Ely whose chord bears S15°10106"E 178.97'' thence
S 30°45924"E 111.561 along said W right-of-way line; thence S24°16t54'E
247.061 along said W right of way line; thence N89°59130"W 178.531;
thence SO°27133"W 1326.511 to the point of beginning. That such plat
is a correct representation of all the exterior boundaries of the land
surveyed and the subdivision thereof made; that I have made such surv~y,
land division and plat by the direction of the owner of said lands;
and that I have fully complied with the provisions of chapter 236 of the
Wisconsin Statutes and the Subdivision Regulations of St. Croix Count
~t
in surveying
dividing and mapping
g the same.
CERTIFICATE OF TOWN TREASURER
I. Beverly A. Johnson, being the duly elected, qualified and act'ng
Town Treasurer of the Town of Hudson, do hereby certify that in accor
dance with the records in my office, there are no unpaid taxes or
special assessments as of September 21, 1979 on any land included in he
Plat of Countryside Village.
TOWN BOARD RESOLUTION--Dated Sept. 23, 1979•
Resolved, that the Plat of Countryside Village in the Town of Hu -
son, Francis H Ogden, owner, is hereby approved by the Town Board.
/s/ David L. Hallstrom, Town Chairman.
OWNERtS CERTIFICATE--Dated Sept. 21, 1979, Ack. Sept. 21, 1979.
I. Francis H. Ogden, hereby certify that I caused the land des-
cribed on this plat to be surveyed, divided, mapped and dedicated as
represented on this plat. I also certify that this plat is required
S236.10 or S236.12 of the Wisconsin Statutes and Section 54.4 of the
St. Croix County Zoning Ordinance and the Subdivision Regulations of
of the Town of Hudson to be submitted to the following for approval
or objection: Department of Local Affairs and Development, Division
of Health, Department of Health and Social Services, St. Croix County
Comprehensive Parks, Planning and Zoning Committee and the Town of Hudson.
COUNTY ZONING COMMITTEE RESOLUTION--Dated Sept. 21, 1979, Aug. 1~, 197'
Resolved that the Plat of Countryside Village in the Town of Hud
son, Francis H. Ogden, owner, is hereby approved by the County Zoning
Committee. /s/ Harold C. Barber, St. Croix County Zoning Administrator,
E.P. Rock, Chairman, St. Croix County Zoning Comm.
I certify that the foregoing is a copy of a resolution adopted by,
iv v v:J Jet ri 1 144.68
9 2.89.91' `211.77' 158.32' 37.55'
_ - 407.64'
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SE CORNER ( RECORDED AS 1 SO°2830"W 1324.21') S0027' -
SECTION 33 1
T29N,R19W UNPLATTED LANDS I UNPLATTEI
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SEPTIC TANK MAINTENANCE AGREEMENT CD
St. Croix County z
d
OWNER/B-"ER
ROUTE/BOX NUMBER Fire Number
CITY/STATE ~~-~r,~~:~~,,,~ _ZIP
PROPERTY LOCATION:;, ~4, Section T--,- N, R
Town of St. Croix County,
cCi '7Yy
Subdivision 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
I
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. H
0
E
I/WE, the undersigned, have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- 'v
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 96
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,
LABOR AND C DIVISION
P.O. BOX 76
PERCOLATION TESTS (115) MADISO
HUMAN RELATIONS
N WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION:; SECTION: TOWNSHIP/N+UNfGlfAt+-T-Y: LOT NO.: BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRES :
5 T tx L t - v 14u.j
USE DATES OBSERVATIONS MADE
[k Residence BEDRMS.: COMME IA DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
[kResidence ❑Replace - c
RATING: S= Site suitable for system U= Site unsuitable for system ,4 Cc_
a I ✓
C NVENTIONAL: MOUND: IN-GROUN9D-PRESISIURE: SYSTEM-IN-FILLHOLMNG TA'NIUR EC OMMENDED SYSTEM: (optio al)
S ❑U ~S ❑Ev ❑V ❑S ❑S lV t_ rA 12 y _.(`)K,`<
[under Percolation Tests are NOT requir d DESIGN RATE: n
I' ( / If any portion of the tested area is in the
s.H63.09(5)(b), indicate: h v// Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-Ifs CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH ,
NUMBER ~iF+N, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
~I S
3
L/, 3 J; ~,z ~
J) IS
B A) A/ I
v7
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
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
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0 13
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E
36
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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:
A RESS: I CERTIFICATION MBER: PHONE NUMBER (optional):
C IGNAT UR
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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Freeb Alt Inleh And Obcervallon Pipe
~1- Approved Vent Cap
Minimum 12" Above
Final Erode
20 - 42" Above Pipe 4° Cost Iron
To Final Grode Vent Pipe
Marts Hay Or Synthetic Covering
win 2" Aggregate
Over Pipe
Olstribullon
Pipe 0 0 0 0 0 - Tee -
Aggregate
Beneath Plpe 0 Pertoraled Pipe Belo,
0 -Covpling Terminating At
Bottom Of system
~L~eJ• all SOIL FILL
DISTRIBLITIOVI PIPE
APPP'0VE0 S4WPT 7TIC COVER
MAT~iill~t- or, 4''OF STRAW
2"oFN6GR~'GATE-~~ OR/~ARSU HAS
AGGREGATE
IELE V. OF FEET
DISTRIFjUTIOH PIPE TO 6E AT LEAST i1JCHES BELOW ORIGINAL GRADE
AtJU AT LEASTZD INCHES BUT KIO MORE THA1J 42 INCHES DLLOW FINAL. GRADE
MAXIMUM DEPTH OF EXCAVATI00 FKOM 0KI&OVAL bkADF- WILL BE INCHES
MINIMUM! ®EPrh of E'XCAVATIOW FKOM OiK161WAL GRAPE WILL BE ` INCHES
UCEI-ISE AJUMBER: f
DATE: 1 t o JF
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