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HomeMy WebLinkAbout026-1113-80-000 n N O E-0 n d _ 1 C s1 C C l9 C 3 7 CD N 1 i 3 O n o m 0 o o c°'o 0 0 t) w t) o m Z o_ = j ~w_~~NWN W Q00W N N O O (O p j Q O C ICI O W cn CO O O N OOO C (p N O 4 CD O O O O S?o O. cn (1) C- 0 CD 0- ° Cn C (n c o ° cn m a W to (D V o 00 O V V cc 0 D Co (D O (D rlj cn Z ;d by a co z lz 2 a O £ ~O ° ccri cOn .°r. Q ~ (D `D d rt !i n o o Z O O O Z ' ~ ~ r~t o o 3 fin N y y CD W P n o o m C O S m o rn m ° m N 3 ~ n d v D F-i ON cn cn o co ° Z z ° (D v, < CD F-3 £ N a a N r I Z O d D CL CD 0 --,j J ° m m m U) 00 -1 CD i CD v 1 (a W 1O c CD CD O w a Oo n E 0° In Z m co ' Ln z (9 ° s n F-3 F-3 u) S w w a A Z T (D Z c o 03 rot F- -a W * o w (D a ~ ~ N o ;u G. O ol r) rt O r: (n Oo o o m Z b A a w w o a D y v a I v n ~ N p - S?o 3 N C c, o Z M _ O_ (D D N N v d C 2,0 1 O H 3 (Oil (OD O N Z N ti ti cr (D N CD O O CD A O Z7 A O OQ O O q Oo (D ti Parcel 026-1113-80-000 10/11/2006 04:10 PM PAGE 1 OF 1 Alt. Parcel 3.30.18.653 026 - TOWN OF RICHMOND 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 - BORGEN, BRUCE C & JUDY F BRUCE C & JUDY F BORGEN 1217 172ND AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 1217 172ND AVE SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.920 Plat: 2021-GREEN ACRES ADD SEC 3 T30N R1 8W LAND BETWEEN LOTS 12 & Block/Condo Bldg: LOT PARK 13 IN PLAT OF GREEN ACRES PLATTED AS PUBLIC PARK Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 03-30N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 718/189 07/23/1997 678/629 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/20/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.920 25,700 117,800 143,500 NO Totals for 2006: General Property 0.920 25,700 117,800 143,500 Woodland 0.000 0 0 Totals for 2005: General Property 0.920 25,700 117,800 143,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 217 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form- STC_ 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T -N-R~W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAIV_VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i t I f -d j T1~4Gy 7! INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: _M) Proposed slope at site: SEPTIC TANK: Manufacturer: sz _ Liquid Capacity: ~ cd 4, Number of rings used: Tank manhole cover elevation: /cc), C)n Tank Inset Elevation:q Tank Oust Elevation: Number of feet from nearest Road: Front,O Sidek.Aj Rear, 0 t ? 0 feet From nearest property line Front,0 Side,0 Rear, © 4~ feet i Number of feet from: well l , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE • R ~ 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: 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: Trench: Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, 0I?t..:.2 Number of feet from well: tl,t~ /t 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector* n Plumber on job- Dated: License Number: 3/84:mj r DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING. LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 IMONVENTIONAL ❑ALTERNATIVE State Plan l.D. N umber. (If assigned) ❑ Holding Tank 1:1 In-Ground Pressure ❑ Mound ( NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE. Bruce B orgen R. R. 2, New Richmond, WI 54017 Y-30 -,RS 1? 30 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. SW SW, Section 3, T30N-R18W, Town of Richmond, Coleman Addn. Narne of Plumber. MP/MPRSW No. Cnu nty. Sanitary Permit Number: Cal Powers, Jr. 1563 St. Croix 69605 SEPTIC TANK/HOLDING ANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED ❑YES ❑NO ❑YES ❑NO BEDDING. ENT Or A.: VENT MATL. J I HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH i ALARM FEET FROM LINE: f LAIR INLET. ❑YES NO - ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER 71YNEG LI QUID CAPACITY JPUMP MODEL PUMP; SIPHON MANUF ACTIIRERWARNING LABEL LOCKING COVER PROVIDEDPROVIDEDS ❑NO ❑YES FIND ❑YES ❑NO GALLONS PER CYCLE: P UMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING .I V ENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLEN(,11 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 NO. OF DISTR. PIPE SPACING COVER JINSIUE CIA 'PITS LIQUID BED/TRENCH 1 / TRENCHES IG-ER AIL,. PIT DEPTH DIMENSIONS •'N a- GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO~DISTR. NUMBER OF PROPERTY WELL [BVILDirif,VENT TO FRESH BELOW PIPES ABOVE COVER ELEVIN ELEV E D PIPES FEET FROM L1 AIR INLET. ~ O ~ ? -1 NEARESTs,-' . i 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES FIND SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED'. MULCHED CENTER EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPF 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 FLEV.. ELEV.' CIA. ELEV.. PIPES. DIA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES FIND ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING: FEET FROM LINE ❑YES FIND ❑YES FIND NEAREST I i I f%~ U / 7 J ✓I ? rt Fy Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. - TITLE. DILHR SBD 6710 (R. 01/82) - ~ wlsconsln APPLICATION FOR SANITARY PERMIT ~ D LHR a~ C" COUNTY OEPARTT I T OF (PLB 67) UNIFORM SANITARY PERMIT # In OL1STRY, LABOR 6 HUMFIn RELRTIOns -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 (LING ADDRESS (1 MP _ r 1 t PROPERTY LOCATION f C++Y: Sw 1/4 SL,r1/4, S , T-u N, R A (or) W TOWN OF un LOT NUMBER IBLOCKNrJMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER A C I "/q A JGE - t~ t:. cit. +"~C; , v, TYPE OF BUILDING OR USE SERVED /►~~J~- >~~~J_ O~Q 1 or 2 Family Number of Bedrooms. Public (Specify): THIS PERMIT IS FOR A: K 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 ❑ 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 I 2L. q 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): . -2 d ( Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation he private sewage system shown on the attached plans. Name of Plumber (Pry I Sign e: $9/MPRSW No.: Phone Number: Ca i f/ Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved "-'pe ❑ Owner Given Initial !r ra"'I"~ 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 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. 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/contractpr,("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 Section , T = N - R > W Township Mailing Address Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel 1 t 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 "X,- 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.6y that att 6.ta tementd on .th i,b 6o,%m ahe fi&ue to the but o6 my (ouA ) know.Cedge; that 1 (we) am (ace) the owneA (b) o6 the ptopeA ty deb c i.bed in .thiA in6o4ma ti.on 6o4m, by viA tue o6 a wannan ty deed neconded in the 06 6ice o6 the County Reg.i6teh o6 DeeA " Document No. i,:l! and that I (we) p4e6enttty own the pnopoded Aite bon the sewage diAposat by.6tem (on. I (we) have obtained an easement, to 4un with the above de6cA bed pnopehty, bon the eon4tAucti.on o6 said 6y.6tem, and the same has been duty necoAded in the 066ice o6 the County Reg-i6ten. o6 Deed6, ab Document No, SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED GRANTEE: R r $ ?ifa w~ Name ,social 4ecwity Plumber Social Security Number Full Address - New address if property transferred was residence Full Address Is grantor related to grantee? Relationship includes, marriage, blood relative, partner, lessee-lessor, ❑ Yes* ❑ No Name and address to which tax bills should be sent if not the same as above , 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( 7 ) Telephone: Grantee ( ) PART 1 - PROPERTY TRANSFERRED PART 11- PHYSICAL DESCRIPTION AND INTENDED USE Cheek proper box and enter name of municipality and county 1. Kind of Property 2. Principal IntendedUse ❑ City ❑ Village ❑ Town a. ❑ Land Only a. ❑ Residential d. ❑ Agricultural County ❑ New Construction b. ❑ Commercial e. ❑ Recreational Street address of property transferred. Include road name and /or fire number. ❑ Building Previously Used c. ❑ Industrial f. ❑ Other (Explain) ❑ Solar Design - ❑ Earth Sheltered Home 3. Land Area and Type Estimated Legal Description (Fill in complete legal description in space below or if metes ❑ Condominium a. Lot size x ❑ and bounds description attach 3 copies of it as shown on the instrument of b. Residential Units, if any b. Total Acres ❑ conveyance. If certified survey map number is used in description list town, ❑ One Family 1. Tillable Acres ❑ range, section and acres.) Tax Parcel Number ❑ 2 and 3 units 2. W.T.L. Acres Lot No. Blk No. Section Town Range - ❑ 4 or more units 3. F.C. Acres L1 Plat Name c. Ft. of Water Frontage x s k""..; '.Yt` . ~a _ i ti~ } .rs. ` 'fi ~ pp t' r: 3 rf 1, 1 F ri? r a... Mr.:'.rt PART 111- TRANSFER (One answer is mandatory for questions 1-4, 5a or b must be completed, questions 6, 7 & 8 as apply) 1. Q Sale 1 ❑ Gift 3. ❑ Exchange 4. ❑ Other transfer (Explain) 5. Ownership interest transferred a. ❑ Full b. ❑ Other (Explain) 6. ❑ Deed in satisfaction of land contract - What was the date of the original land contract? 7. Amount of mortgage assumed by grantee? $ 8. Does the grantor retain any of the following rights: ❑ Life estate ❑ Easement PART IV - ENERGY Is this property subject to the Rental Weatherization Standards, It HR 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 V - COMP~ATION 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 local property tax (Solar, wind, M&E etc.), but exclude personal property $ 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 1-13 (see instructions") Sec. 77.25. ( 1 s 5. Fee - thirty cents per one hundred dollars of value (line 1 times .003) Make check payable to Register of Deeds $ PART VI - CERTIFICATION The transfer must be reported regardless of the grantor's state of residence. Information on this return will be used to administer Wisconsin Income and Fran- chise Tax Laws, Wisconsin Real 'Estate Transfer Laws and Wisconsin Rental Unit Energy Efficiency Laws. We declare under F enaltyy.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 ar com Mete. _ the Si Phature of Grantwr or Agent - ~ Date Print or Type Agent's Name SIGN _ t ti HERE signature of Grantee or Agent D) ae- Print or Type Agent's Name y If Signed By Agent Agent Address Phone b. Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance LEAVE r,` :~Wlt 4: r..: 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 A 6 C D E F T T Ratio Consideration School District No. PE-500 (R. 7-85) H z H a _ ST C- 105 r r a ti SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a OWNER/BUYER H ROUTE/BOX NUMBER Fire Number CITY/STATE 1 ZIP Section T N, R f W, PROPERTY LOCATION: ;..t. 24 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 If 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. 'A 0 E I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- 10 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 ~ X 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. o ~ _ L O J CD w 'r cn r > O -o C z. E o c a)~ c~ rQ ~aS a4~ Eoo Eo E=3 o .-a) >L -a OC ~ . \ ) 0 j V C 4 ~Y (D N ~ O "a 0CD U L Co 0 C O) C 4 °~'a,o U N E Q) Y 0) D U)Y o 3~~ m ov ~n W ° w 3:2 nom vE c rn . 0 0 0 0) :3 0 c~U L C N O N c N cn i a) O L_ O O Cc s ca ca W ~o3 U» ~mN 3 0) 'v r- v) v d N cd c c U - L (D 0 as =3 :E -0 CC 0 CC W rn 3 o (D w Q Q (D E 0Ena) -0 C BE H- Q) L U CD L a) ny U. c F- ' i N L 0 1. U n Q U) to - Z 0 0 cYOU a 0 co a) cn O co " 0) am., o O 3. ~2on L cr. 0 C3 o ~o 0) M lL cc- Q "Cr aa~o - ■ C a) C O T cn - Y 0 C (u L C ?i C > O 0)Z C U-0O E> O O E cn~00~ o w c c L C c Y ~ocvo~ ~a)o Crj 0) 0) L- O p E U 00 a) O O U L (D 0) M C C a) U a) C cn co ,T co ca _ OHO N 00 a O N o 0 CD cn a) O N N a) CL O Y O n c C O 0) 0) j E c> Q) •L• N Y cv m O O L - O fA °o° ~LL E~ i n C 0) U U ~Y 0 0 3 O oEcvrnw~c«° f-°? vcn C O a) c L a) N m 0L C = N 0 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, G DIVISION I P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: .,41TOWN HIP/MifNtCiPRLITY: LOT NO.:BLK.IF. : SUBDIVISION NAME: CgVNTY: OWNER'S/BUYER'S NAME: MAILING ADDRES : USE DATES OBSERVATIONS MADE Residence NO.BEDRMS.: COMMERCIA DESCRIPTION: 2 New PROFILE DESCRIPTIONS: PERCOLATION TESTS: ❑ Replace > - - rS~ 7 RATING: S= Site suitable for system U= Site unsuitable for system " CONVENTIONAL: MOUND: FlGROUND-PRESSURE: SYSTEM-IN-FILL LDING TANK: RECOMMENDED SYSTEM:(optional) ®S ❑U S ❑U S ❑U ❑ S ®U ❑ S [Z U - 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: n Ila PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B B - C B 2 Z -,2 LL, z, 22 -_2 JS _L Z 1,S,6ALW B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER R4GH-ES AFTERSWELLING INTERVAL-MIN. PERIOD PERT 2 PERT 3 PER INCH P- 7 ' 1 s~ P-,-- ► s . s 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 C 1y3 E i I 57 -7 L'.b P E I N All- i ~cf/w,osR j - - m _ n 3 i E 27' A I ' V s 3 < 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 ( rintTESTS WERE COMPLETED ON: ADDRE CERTIFICATION NUMBER: PHONE NUMBER (optional): i CST AT R E DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER d'i s sus ask ti >li Lv oe a ec r , €lett, and arc xEr„d 1:' t,hl +l( i..1, r1 tBs it. cte t).' w U',, f an'I , E r,,,ft?l,~~eU C.', "h, SL[1T..., tz t,ilj r<#8,. i.Z a1 e C ts. PLEASE use 3`r?=.F eRl3ljtE,viations shoo` n here for t'v ~Ti~Ig (I(,s PiPE: ons !od (.omr)le_ irlq thnlot pl<+°,. ie€rr5c# OA l<;1 I_ ill <6itr<r E:Fr,r, ,t:l t lc,cati'Io your tit locat.o S. Diavving to scale. ore 3t'dav d•- u -,d !f rde,„ii dI r ar ` ra - Bef- 1 s t" to P(.Ec~, T perc d Y S<t; d ldn t. a t.1 r cmt; - G EFtC:= i , ...,E ; f S, S Clay Q rv~~, ab gyn. jkl11K Co r Aed ize~ g2- C Sci71c.-rig nK - ~c)w Yo 44 64e-r' c-h M c r, k Aj<u i n Pe we r- £ L. / cac, C3 i /C ~I JI - f r 1 ~ / fi- `_,t.~ ~ _ i_u1 L~raF