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HomeMy WebLinkAbout032-1055-20-000 '0 C) M ~ cn a p o N ~ C O O ~ C b O O N ' I N I' I i C N O O Z C 6 LL c O I I ~ Q ch N J-J N S~ ^ z N D Q) ~4 O) W H p 11 r:i Z O U O PC) z a1 3 in Ln `m d rn 00 ch W a m -4 LH pq I N H (n P4 0 ,-4 o W I - c U' a Z ,Zi O Z c w (Y) 0 avi Z ° o H H 000 I fA H ~ m N Z i c~ I W N N 7 N N Q 'i H , m CD N d L - H p co Q z m Z o o c ~ 00 N N y z 3 r- I a) N co z rn N -'h C r a) c H n IL a ` 0 3 ni D D IL m Ra H O LO E 4J 1 Z-t > N H~ H U a1 a d m O M S~ • ie a a a N r~ N a > a o o o - ~ w cn ~ v 3 0 a~ co 00 N uN J U rn 0) } v°) O > in c IL Q m - - m ¢ in o p Y C N N C 1V O O LL `c 30 ~ U Q) 7 (O Q N~ N f~06 N 106 a N N C p of N U c ma) c Z: -0 z CO a) CD z -2 E CO 0 *6 (n , • >OO O N U) > r- O Z N 2 H CO a..!, E N L a) M 0 a • ee O- m d v c m c t A 0 at I0 U) Parcel 032-1055-20-000 11/22/2006 10:25 AM PAGE 1 OF 1 Alt. Parcel 21.31.19.272F 032 - TOWN OF SOMERSET Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner GARY WOLD O - WOLD, GARY 476 208TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 476 208TH AVE: SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 5.035 Plat: N/A-NOT AVAILABLE SEC 21 T31N R1 9W 5.035A IN N1/2 SE NE Block/Condo Bldg: LOT 4 CSM VOL 4 PAGE 1170 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-31 N-1 9W Notes: Parcel History: Date Doc # Vol/Page Type 01/26/2000 1317373 1486/69 QC 07/23/1997 706/96 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.035 58,100 148,800 206,900 NO Totals for 2006: General Property 5.035 58,100 148,800 206,900 Woodland 0.000 0 0 Totals for 2005: General Property 5.035 58,100 148,800 206,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 119 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 C a-0i Co 0 M y O t c ~ o a O N Cl. ~ C~ c O c ? O N 'B C (9 o r7~ L °r M C O 'O C U) O N O_ O f0 C E Z E 3 (II LL c fn ` 0 N 5 L 0 Q fn 3 Cl) v v Z o rn w E Z O N O Z d d y M w a m ° N F- cn C) O O Z d c v w C N Z a E fq F- r O N ~O C E O_ _0 N N N N O U1 o_~/\I N a c ca o C N a) or- E • ~ CU n d L C O c c Z co z O o O a N C) EE a a Fu o v N y m ° N 0 0 a n m If fn •w m a a a a w w .n o U) 0 ,n ,n N of ~ fn J U w rn rn OD Q) } CD A I O o ~ ~ a~i °o w cn~ O Ec~ 00 N Q m y = d O) ~ y N ~ (3) L O Q } Cn m 2 C O O N N C LL 3 ( O E O C~ n H "t N tls O ~ C. V (1) 0 C U d c) b FL~i N Lo C m y C a ON N N C N j (6 O N _ W ao y "o Z -o C%4 2 _ >>O O N (n > r 0 Z y 2 H U) E cD V E C L) a •C~ Q4 E d . C y C r~ 3 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ' r //c TOWNSHIP ~ SEC. - ~ T LN-R W IL ADDRESS ,eI ST. CROIX COUNTY, WISCONSIN lG~ ~ SUBDIVISION LOT LOT SIZE l PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i~~lb ~6tf7 dl~e //D C,6 r ' INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ,?c,. fT~y jf>~~ ST ' e Elevation of vertical reference point: 1~262 Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: _ Z2 Tank manhole cover elevation: Tank Inlet.Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side Q Rear, O / /5-0 feet r From nearest property line Front,0 Side,Q Rear, O J_5 feet Number of feet from: well /1/0 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 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: A~ Number of Lines: i Area Built:" Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,0 Int. Number of feet from well: ✓y 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: Dated: Plumber on job: License Number: 3/84:mj ` Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT TOWNSHIP SEC. T N-RW OWNER ri L'c>~ ADDRESS 6 1t)'?-ei- ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE fG lC C PLAN VIEW Distances and dimensions to meet requirements of I1HR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM R 1 I I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: / Gt~ Proposed slope at site: -e- SEPTIC TANK: Manufacturer: 'g2 e Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,© Rear, O /5-0 feet j :-From nearest property line Front,0 Side,Q Rear, O feet Number of feet from: well'" GJ~/ building: s6 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53107 CONVENTIONAL ❑ALTERNATIVE state Plan ID Number. l El Holding Tank ❑ In-Ground Pressure 1:1 Mound 11 1 assia ned NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECT I BATE Gary Wold R. R. 1, Somerset, WI 54025 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT ELEV SE NE, Section 21, T31N-R19W, Town of Somerset N--of PWnd>er.. IMP/MPHSW Nr, ary Per,nit Numhe•. Byron Bird, Jr. 3318 St. Croix 74988 SEPTIC TANK/HOLDING TANK: 1MANUFACTURER. -1 I LIQUID CAPACITY TANK IN LET ELEV TANK OUTLET ELF. V. WARNING LABEL LOCKING COVER _ PROV IDED. PROV IDED I J C_ ~-,r YES ❑NO ❑YES NO BEDDING'. J J VENT DIA.. VENT MATT HIGH WATER NUMBER OF ROAD PROPERTY WELL 1111LDING f NT TO FRESH ALARM' LINE i R I NLET ❑YES ~'NO FEET FROM 4 r -7 LYES O NE_A_R_EST_ l / 1'~J DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACIT V PUMP MODE I PUMP SIPHON :'ANIII ACTUHE H W HNING LABEL JLOCKING COVER ❑YES PEJOVIDED PROVIDED ❑NO ❑YES ❑NO LJYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERAT IONAE NUMBER OF PROPE 141'4 WELL JBUILDING (VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM PINF AIR INLET PUMP ON AND OFF) ❑YES L_1N0 NEAREST--310 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ~nA91E TE H AT[ PInL aNI, MAHKIN(, 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: BEDITRENCH WIDTH LEV n/ No or , T PIP( la lr c(>vFI+ -;E rnn - =PITS uoulD ( iHfIES ran CEjlln, PIT DEPTH. DIMENSIONS 4+ - GRAVEL DEPTH FILL DEPTH- 111i11111 ,PIPE DISTH PIPE DISTR PIPE MATERIAL NO D1SIH NUMBER OF PROPERTY WELL BUILDING VENT TOFRES F L OW PIPES ABOVE COVER INII ELEV END, PIPES LINE p AIx/c R ~~3 ~ / r FEET FROM - / < 'L ` -,r NEAREST► 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- ❑ Y ES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER rexn/RI E TMANE N T MAHKE IIS oHSEHVATI(,N WE -L I S E. ❑NO ❑YES ❑NO DEPTH OVER TRENCH BID DEPTH t)VFH THEN(:H H, 10 OF P1H 04 TI)PS(,II Sc)I,f if I, SEE DFI, MULCHED CENTER EDGES ❑YES _ ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF EATEHAL SPACING GRAVEL DF PTI/ HE LOW PIP( FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE JMMATERIAL NO TTTTH -if PIPE DISTHIHUIION PIPE MATFHIAL&MARKING ELFV. ELEV DIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION _ INFORMATION DOLE SIZE HOLE SPACIN(~ DRILL ED cOPHECI I Y JCOVER MATFHIAL VEH TICAL LIFT CORHESPONDS TU APPROVED PLANS L~ ❑YES L-1 NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS. JOBSERVATION WELLS. tPNU MB ER OF PROPERTY WELLEET FROM LINE ❑YES ❑NO ❑YES LJNO EAREST- r Sketch System on Retai~ county file for audit. Reverse Side. SIGNATURE TITLE - DILHR SBD 6710 (R. 01/82) _ I?Z wlsconsln APPLICATION FOR SANITARY PERMIT f / DILHR OUNTY OEPRgTR1EnT OF (PLB 67) UNIFORM SANITARY PERMIT # In OUSTRV, LRBOR 6 HUTRn RELRTIOnS I!Y 91 -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 MAILING ADDRESS PROPERTY LOCATION CITY: lil 1 /4 1 A S , T' N, R E (or J ~ F: LOT NUMBER JBLOCK NUMBER ISUBDIVISION NAME AREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 03.2 - ~,l_ : G 6 1 or 2 Family Number of Bedrooms. Public ecify): GCJ V w 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 ❑ 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 - El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: c 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): LA~ Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur r MP/MPRSW No.: Phone Number: Plu er's Address: Name of Designer: L h - COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved of ~7G lj~ L~ Owner Given Initial qc~ ©l t} 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 L 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 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 & ee F,y CLIO Location of PropertY.j ~-14, Section T ) N-RW Township Mailing Address Address of Site l n f't"~" z U) ( S YC~za~ Subdivision Name Lot Number Previous Owner of Property wlAese Total Size of Parcel Date Parcel was Created l~ ~L 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 Warranty 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) ceAti6y that a.ee statement,5 on this boAm aTe ; tue to the best o6 my (ouA) knowledge; that I (we) am (ate) the owneA (.s) o6 the pno pen ty des cfc ib ed in th us in6oAma ion boAm, by v,ivttue o6 a waAAanty deed necotLded in the 066ice o6 the County Regi step obi Deeds" Document No. 3 ; and that I (We) pne~s entf-y own the puposed site bon the sewage di,5poSaY_ system (on I (we) have obtained an easement, to nun with the above da nibed ptopenty, 6ok the coutAuc ion o6 said system, and the same hays been duty tecotded in the 046,Lce o6 the County Reg-i~steA o6 Deeds, ass Document No. ) . 7~)~R SIGNATURE OF ER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED xtinTrrr / - . . ~ 1 4 S.2/ ITS/ N/ TOWN ~ ,54,ZCOUNTY `Z , x PLUMBER ISCENSE NO. MPRS3318 DATE - BEDROOM_~af CLASS PERC _ CONVENT IONAL~X IN-GROUND PRESSURE- CONVENTIONAL LIFT_ MOUND.- HOLDING TANK- _EPTIC TANK SIZE .o LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE :BSORPTION AREA = PERC RATE ? `l RED SIZE l8 F! JuHG//C/H ~°/YC ~nC✓~'/~ fIf/Qr 7 Pei l:? tt ~ v 4rt L.; fro ~3 J j C (7rf ' 3 If-~ + Na45C~ i 05, . Z,n r z• ; H z H ST C- 105 r r a ti SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d OWNER/BUYER ~C~J l~Jpl f') ROUTE/BOX NUMBER ~7X 313 Fire Number CITY/STATE ~ tP~$ 1.,AJ ZIP ' gO2-S_ PROPERTY LOCATION: )t, /VE 14, Section z T ~j 1 N, RIC W, Town of ~o'1' +e1 -e_ , St . Croix County, Subdivision C 6, C,, i , 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. 0 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- ro 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. v CO) P~ m x ~ x _ N w C C N v ~ Vi w ~ J 44 O 7C o 0 CD 7 K) a3 Dt° Go 0 _ ~co C 0 (s z ' _O (D 'D a (D COD O Oyi Mg000 CD ~mww9- -0E -1 CD (n <L r cn~-+m ~°oCD mao o 3 a. ° ~n 0 w 0 CD w o 0 r- ° ° L C w ' N 3- C O c 3 0 d 0 W ~ ~ ~ ~ ~ w D~ cn 0 00 0 d fD (D CO w w Co ~v v °D < Cw v'?c0 sr- CD ~ o _ G) N o A° o CD w( o aa~w !A (D Z a~~' A ~wN D CD CD CD CO _ (D CL m 0 3 N? n CD =r 0 ,.tea =0w0 Er - u,wa 2c0 =r CL *M~ C Cl) "a 11'1 v 3 w o .0 CD ~w CD N Err =r o _aw 0_~ w v m w Ch 0 j CD cS n O w_ ~Q w V~ ao~ ycca0)io m w3w_ m-vCDNv a o m OL aErr (A ar E; CD CD0C G)tOn 0tn~~w0 ~7 g d° 7 O t0 C (D C N ro CL 0 CD o ~ pQ a0-' 0-3 a o - CD co °~l z 0 c a ~ 9 ► t 1n D &;ASTR F,NT OF REPORT ON SOIL BORINGS Rr SAS Y & BUILDINGS IN~;,ISTRY,, "~•rr DIVISION LABOR AND PERCOLATION TESTS (11 MA. 4 ~ MA O.0. BOX 76 N WI 53707 HUMAN RELATIONS 32 LOCATION: SECTION: TOWNSHI - LOT NO.• K. NO.: typjlQtVISION N, E: /T--7/ N/'E ( r) W r✓L E -7- : OWNER'S BUYER'S NAME: MAILING ADDRESS: ~`>J COUNTY USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILE TONS: 1PERCOLATION TESTS: K:XgRdence ___4 $New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S0 U S❑ U _RS❑ U g S❑ U g S❑ ll If Percolation Tests are NOT required D_EStGN RATE: :~lEM EL V. If any portion of the lot is in the under s.H63.09(5)Ib1, indicate: , y~~.(✓' C Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- C:: C3 P- p PLAN VIEW: Show locations of percolation tests, soil borings and the dirridWoM of suitable soil area 51ale o r distances. Describe what are the hori- ion at all borings and the direction and percent zontal and vertical elevation r nd show their location o he plot plan. Show the surf ~Pg of land slop. 7 , SYSTEM ELEVA ` IF " v y, -7 G - C . _ i N ,0 c~ 41C e__ '4 4.✓ ~ ` N "APPROV .4~_ 4 'lr_. Dates Sf s~ 8 4 -Z Inspectok y i, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative 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: c J F L_ E_ cif/, ~ t i /r_+')~ S~ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): STS NATURE: d DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Prope er, 4th page Soil Tester. DILHR-SBD-6395 (N. 03/81) , , y . C U e t a t v fi 4 1 r t a t L L n ♦N t e • ~ e d f 5 r. 9 u i i