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Parcel 032-1065-95-100 02/10/2006 05:10 PM
PAGE 1 OF 1
Alt. Parcel 24.31.19.327E 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): O = Current Owner, C = Current Co-Owner
O - BAILLARGEON, RICHARD M & CARAN L
RICHARD M & CARAN L BAILLARGEON
738 72ND ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 738 72ND ST
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.830 Plat: N/A-NOT AVAILABLE
SEC 24 T31 N R1 9W NE SW THAT PT OF LOT 5 Block/Condo Bldg:
CSM 6/1518 ASM'T INC 032-1067-40-100
332C Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
24-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 710/258
2005 SUMMARY Bill Fair Market Value: Assessed with:
77167 348,500
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.830 62,500 218,000 280,500 NO
Totals for 2005:
General Property 3.830 62,500 218,000 280,500
Woodland 0.000 0 0
Totals for 2004:
General Property 3.830 62,500 218,000 280,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 135
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 032-1067-40-100 02/10/2006 05:11 PM
PAGE 1 OF 1
Alt. Parcel 24.31.19.332C 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): O = Current Owner, C = Current Co-Owner
O - BAILLARGEON, RICHARD M & CARAN L
RICHARD M & CARAN L BAILLARGEON
738 72ND ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 24 T31 N R1 9W NW SE THAT PART OF LOT Block/Condo Bldg:
5_- C.S.M 6/1518 ASSESS WITH P327E
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 701/258
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2005:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 0 0 0
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
Parcel 032-1067-40-000 02/10/2006 05:11 PM
PAGE 1 OF 1
Alt. Parcel 24.31.19.332B 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): O = Current Owner, C = Current Co-Owner
O - BAILLARGEON, RICHARD M & CARAN L
RICHARD M & CARAN L BAILLARGEON
738 72ND ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE
SEC 24 T31 N R1 9W SW COR NW SE EXC PARCEL Block/Condo Bldg:
332C ASSM'T INC 032-1065-95 130
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-31 N-1 9W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1126/539 WD
07/23/1997 727/77,
07/23/1997 710/258
2005 SUMMARY Bill Fair Market Value: Assessed with:
77184 59,600
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.500 48,000 0 48,000 NO
Totals for 2005:
General Property 2.500 48,000 0 48,000
Woodland 0.000 0 0
Totals for 2004:
General Property 2.500 48,000 0 48,000
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
ST. CROIX COUNTY ZONING OFFICE
911 FOURTH STREET
HUDSON, WI 54816
St. Croix County Sanitary Maintenance '14, Sec ~t')
Certification Form for system installed during 1985 -7L
--------1. The private sewage disposal system is in proper operating
X condition.
---`----2. The septic tank was recently pumped by a licensed septic
tank pumper, or it was inspected and is less than 113 full
of sludge and scum.
Signed by
Time Gf; d0Day Month Year /Cjff~?
Signed by`` Owner A,6 Ql~
Time fM, Day Month Year Jug
Make occupant or address corrections here Ia na ";f .
.~ow~r~,e~ lA~ l S~0 a
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
;
OWNER TOWNSHIP /i SEC.
ADDRESS Xy ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
A
1!
~rJU
.
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
,~;.i
d~
Elevation of vertical reference point: PZ,',o Proposed slope at site:
SEPTIC TANK: Manufacturer: % 4,iquid Capacity:
Number of rings used:- Tank manhole cover elevation: _
Tank Inlet Elevation: ? Tank Outlet Elevation: --L7
Number of feet from nearest Road: Front,0 Side,o Rear , feet
From nearest property line Front,0 Side Rear, 0 feet
Number of feet from: well - building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
+ f
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: Jt Trench:
Width: / Length: Ij~ Number of Lines: Area Built:
Fill depth to top of pipe: - 0
Number of feet from nearest property line: Front, O Side, 0 Rear,0 Ft
Number of feet from well:
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: 12
F._ Plumber on ob:
Dated.
/
License Number:
3/84:mj
DEPARTIMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
WI 53707
MADISON, WI 53707
32MNVENTIONAL ❑ALTERNATIVE -ePanl.D.Number
111 assign edl
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTIO DATE.
Richard Baillargeon R. R., Somerset, WI
BENCH MARK (Perrnaneor reference poem) DESCRIBE IF DIFFERENT FROM PLAN. REF PT LEV.~C ST REF. PT ELEV.-
NW SE, Section 24, T31N-R19W, Town of Somerset
Name of Plumber. MP/MPRSW No. County. Sanitary Permit Number.
Cal Powers, Jr. 1563 St. Croix 64862
SEPTIC TANK/HOLDI TANK: )
MANUFACTURER. LIQUID CAP/ITV. TANK INLET ELEV.. TANK ELEV.. WARNING LABEL LOCKING COVER
J1 I PROV ED: PROVIDED
YES LINO OYES LINO
BEDDING: ENT DI VENT M TL. HIGH WATER NUMBER OF ROAD: PR OP ERTV WELL BUIL ING- VENT TO FRESH
C ALARM
f LINE / AIR INLET
FEET F
❑YES LINO ❑YES LINO IN EARESTRO
M
DOSING CHAMBER:
MANUFACTURER BEDUING. LIQUID CAPACI iY PUMP MODEL. PUMiPHON MANUF ACTUREH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES LINO ❑YES LINO ❑YES LINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FR ESH
'
(DIFFERENCE BETWEEN FEET FROM LINE IAIR INLET
PUMP ON AND OFF) ❑YES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I FN(,TH J I DIAMF TER MATERIAL AND MARKING
o: 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 WIDT LENGTH, NO. OF DISTR. PIPE SPACING, COVE JINSIDE CIA -PITS LIQUID
e 7
11 TRENCHES RI L PIT DEPTH
DIMENSIONS LI C'
GRAVEL DEPTH FILL DEPTH DIST PIPE DISTR. PIPE DISTR. PIPE MATERIAL. N DI PROPERTY WELL. ING. VENT TO FRE
BELOW PIPF~S ABr.~(E~VER E VO INLE LEY. END PIPES NUMBER OF i LINE AIR''~LE
FEET EAREST
~Wp C 72 7 N
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 LINO
SOIL COVER TEXTURE PERMANENT MARKERS rIlSEFIVATIONVIILIS
❑YES LINO ❑YES NO
DEPTH OVER TRENCH:BED DEPTH OVER TRENCH: BEO DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR T
I
STRPIPE DISTRIBUTION PIPE MAr ERIAL & MARKING
ELEVELEVCIAELEVPIPESIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES LINO ❑YES LINO
COMMENTS.,.r PERMANEN T MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING
1 ~ FEET FROM LI"E'
{ J 0 ❑YES LINO ❑YES LINO NEAREST
f ,Z~ S . c~ t
75
r
Sketch System on Retai m county file for audit.
Reverse Side. '
[IGNA , T TITLE
DILHR SBD 6710 (R. 01/82)
wisconsin APPLICATION FOR SANITARY PERMIT r
®ILHR COUNTY
- OEPRRTfT1EnTOF (PLB 67) UNIFORM SANITARY PERMIT #
In OUSTRV, LRSOR 6 HUMRn RELRTIons
Y J
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP TY OWNER MAI ADDRES
P PERTY LOCATION -4-TY:
VFW{-AGE:
11' 1/4, , N, R (or Ill ' TOWN OF: 41tr
LOT NUMBER IBLOCK MBER SN NAM NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED -
4 1 or 2 Family Number of Bedrooms. Public (Specify): zo~
_
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repa'
❑ 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 L~ 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
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):
/ e Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation o the rivat sewage system shown on the attached plans.
Na o~f/P umber (Pri t): Sig e: MP/MPRSW No.: one Number
Plumber's ddress: q Name of Design r:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Disapproved
(rte / ~jr ~I ❑ Owner Given Initial
/ j' y Z $ ~4 / j Et f1 `J )(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:
I
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 Lorne is to be completed in lull 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 corm should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
l,ucation of Property Section T,SZ N - R W
1'own:31li_p
Ma i 1 tag Address
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? No
is this property being developed for resale (spec house) ? Yes No
Volume ~ and Page Number 11 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICAT-1-ON-ONE. OF THE FOLLOWING:
DI: Warranty Deed
Land Contraci
V Other recording: filed with tb~ Kegl=er ui Dweds 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 Gurti_f ied Survey Map shalt also he required.
PROARI V OWNER CERTIFICATION
I (We) eetti{jy that all statement, on this jotm cute hue to the best o6 my (Ours)
hnowtedge; that I (we) am (arse) the owners (s) oA the pAopenty dacAibed in this
injoAmat%on 6yhm, bC vi tue o6 'a wat4an-ty died Aecoh.ded in the 06liee of ,the
County RegiAn o6 Deeds at Document No. and that I (we)
pesent y own the proposed site 4oA the sewage disposal system (oA 1 (we) have
obtained an exleme.nT, to nun with the above dacti.bed pnopekty, 4oA the
eonstAuct on )I sav system, and t-ne sam, a,- ` Ovn duty Ac: z%AW f q the 016ice
o6 the County Regis,ty o{j Deeds, as Doeiutieri.t No.
) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DA-117, SIGNED DALI' SI NEI)
H
Vi
H
y
r
STC'-105 r
y
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
9
\1 H
OWNER/BUYER kA
ROUTE/BOX NUMBER p °U Fire Number
CITY/STATE SOVvl I- ZIP 5q17,~
PROPERTY LOCATION: 14, 4, Section , T N, R _W'
I
Town ofSt . Croix County,
Subdivision Lot number
improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
I/WE, the undersigned, have read the above requirements and agree cn
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart-
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. e
SIGNED
D A 'r E
St. Croix County Zoning Office
P.O. Box 98-
Hammond, WI 54015
715-796-223S) or 715-425-8363
Sign, date and return to above address.
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1
1EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUS DUSTRY4 DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 796
HUMAN f$ELATIONS
N WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION:
SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
fl, N/Vlw,
1/4
C LINTY: OWNER'S/BUYER'S NADAE: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIA DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
Residence % r New ❑Replace I` ti-
RATING: S= Site suitable for system U= Site unsuitable for system . , i'
CONVENTIONAL: MOUND: l--GROUND-PRESSURE: SYSTEM IN-FILOLD NG TANK: RECOMMENDED SYSTEM: (optional)
❑S ❑U S ❑U ❑S ❑U ❑S ❑UL H❑S ❑U
If Percolation Tests are NOT required/ DESIGN RATE: I If an
IL y portion of the tested area is in the
_1 1I
under s.H63.09(5)(b), indicate: /F Floodplain, indicate Floodplain elevation: / _
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
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PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIO 1 PERIO 2 PER10 3 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 elevati~ at all orings and the direction and percent
of land slope.
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SYSTEM ELEVATION
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1, 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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGN URE:~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. -
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Fresh Alt Intele And Observation Pipe
- Approved Vent Cap
Minimum 12" Above
Final Grade
,'U - 42" Above Pipe 4" C a al Iron
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To Final Grade Vent Pipe
1AOr sh Noy Or Symhelk Covering
min 2" Aggregole
Over Pipe
Distribution
Plp• o o o 0 0 -Tee
6" Aggregole o Perforated Pipe Below
Beneath Pipe
0 -Coupling Terminating At
Bottom Of System
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SOIL FILL
DISTRIBUTI01`1 PIPE
APPROVED ~4MT►-IE7IC COVER
OR 911 OF STRAW
2" OF hG REGATE c OR MARSH HAS
(oCIF AGGREGATE
ELEV. OF'<~e-- FEET
60
DISTRIRUTI':~IJ PIPE TU BE AT LEAST yX-K_ IIJCHES BELOW ORIGIfUAL GRADE
AML AT LEAST ED IUCHE-'~ BUT l.IO MORE THAkI Ha IUCHES BELOW FIAJAL GRADE
MAXIMUM DEPTH OF EXCAVATioo FKoM oWN4.L 6KAK- WILL BE IAJCHES
/AwIMUM! ocfr" OF EACAVATImN fRoMM c*►(ji►bAL 6RAp€ WILL 6E I Ir~cHEs
SIG"ED :
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DATE: ~ 122C
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