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HomeMy WebLinkAbout020-1156-40-000 n U1 O 0 to O m v 0 C7 ~ 1 o a d F ° (D m .0 C m m 3 M 3 O d > (n O O CD 0 y N (n O 4- D_ N O to cn L A iZ d N Q O =D o ( O n N > > O n N C CO Cn (O Cn 0O~ 1 N N Q 3 O~ .7 W O M :3 -u 0 O O c CD j (CD ° O1 v N c C 00 O 3 co 3 O K l~ 7 N (CD 7 N C O O o (A < O Z a -1 r- CD o 0 o y CD ;o cn < D CD o ° cn D a (D Cp (D (n a N (D (L] CD N a O (D C _ (D C CL 0 O N N° a ° CD (0 j N O CD N W hr --n L -4 N O C O CD CD co C.0 P o r- en 00 co N 41 A C N W N N M Q Z Cil O Z 0 0 0 rn Z 0 0 0 ° • o ;t S N N O fn sv ' r3 -4 --1 --q 0 o N. 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C-i~GI-X--C-OUNT"YI---WISCONSIN SUBDIVISION LOT / LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM j } 1 f~. j J f. 1 ,t Ft t INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: ,,t' Liquid Capacity: 11 Number of rings used: cj..% Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side,0 Rear, 0 - feet From nearest property line Front,0 Side,0 Rear, O _ feet Number of feet from: well 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: t Length: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: "Front, O Side, Rear, 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: Dated: Plumber on job: i r~ License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, W1,53707 / ,J~j~,,~ • ❑ CONVENTIONAL ❑ ALTERNATIVE IS,,,, Plan LD Number ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound PRE-EXISTING PERMIT AND SYSTEM INSTALLATION NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE. Jack Lee Ttout Btook Rd, Huct6o , WI f ~z- j9 _S;y BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV.. NB SW, See.17,T29N-R19W, Town o4 Hud,5onjot#77, PoAk View Elstat" Name of PI. hen MP/MPRSW No County Sanitary Permit Number. WiUiam SchumakeA 6382 St. ctoix 58925 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK, L€ ELEV.. TAf~}!9 OU tT ELEV.. WARNING LABEL LOCKING COVER _I `✓'7 / PROVIDED: PROVIDED: OYES LINO OYES LINO BEDDING: VENT DIA VENT MAIL HIGH WATERN UMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH ALARM. FEET FROM LINE LAIR INLET DYES LINO DYES LINO NEAREST DOSING CHAMBER: MANUFACTURER BE DDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. OYES LINO DYES LINO DYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING (DIFFERENCE BETWEEN FEET FROM LINE IVENTTOFRESH AIR INLET PUMP ON AND OFF) DYES NO NEAREST 01 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLEII(;TH JUIAMET111 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: i r t If BED/TRENCH WIDTH LENGTH NO. OF , DISTR PIPE SPACING COVER J INSIDE DIA. -PITS LIQUID L TRENCHES MATERIAL: + PIT DEPTH'. DIMENSIONS 1] GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DIST NUMBER OF PROPERTY BUILDING: VENT TO FRESH BE LOW PIPES. ABOVECOVER ELEV.IN LFT ELEV ENDS PIPES LI AIR INLET. 'A d FEET FROM NEAREST--vi 11 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- O YES LINO meets the criteria for medium sand. T IONS MEASURED. SOIL COVER TEXTURE r EHMANENT MARKERS JOBSERVATION WELLS OYES LINO OYES LINO DEPTH OVER TRENCH'BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES LINO OYES LINO OYES NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. TNRO.EOFNCHES LATERAL SPACI BED/TRENCH NG. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTHIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. CIA ELEV.'. PIPES'. CIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES NO OYES LINO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: OYES LINO DYES LINO NEAREST q Sketch System on ---Retain in county file for audit. Reverse Side. [IGNATUR,E. TITLE. DILHR SBD 6710 (R. 01 /82) ` r w'S~onsin APPLICATION FOR SANITARY PERMIT (PLB 67) COUNTY ~r D1,LHR ~ oEaRRTmenTOF UNIFORM SANITARY PERMIT # ~ In0USTRV,LRB°R SHUTRn RELRTIOnS 1- -Attach cofTTpl"ke 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 MAILING ADDRESS e PROP TY LOCATION CITY: 1 /4.1 b1/4, S % /T,_1 ''N, R l E (Dr t TOWN 'LOT NUMBER BLOCK NUMBER SUBDIVISION NAM rEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER I , 14Z -1 y TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ' ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ( Repair ❑ Replacement Soil Absorption System U Revision ❑ Privy i❑ Alternate System L~ 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 F Existing, For Which A Previous Permit Is On File, Permit # 7~ Z 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 ~-•r Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: l - A1j 1' a_ L 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. Name of Plumber (Print): Signature: MP/MPRSW No.: Phone Number: f ✓ "e7 Je Plumber's Address: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved Owner Given Initial / j Adverse Determination Z Z: App 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 t 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 '12 F 4 3 ~ t - `...mss.. iu y c~ o F z.~ 0~ a l~^o EO o co: co: a) j ° E :3 v3 1 v cif L O o v 0 O)O c 0,0 L- p U O 'a L- O m 0 (n y ) C 3 `'Z ui ~.0 W o (0 -0 =3 3 o v0 C'3 ~3°-0 =3 vEc bo cc Nai.c0) cm O U) 0-- < O = U > O _ O I c~~♦♦ c O G v N (D O O 'n (D v) C L= a) i m m ~.E~ca)CL E o co m N (n o C I w N a) 3 ° -0 ca N 0) r- C C U_ •N Q) a) U) p '0 Co W E U rn3 w ° a) Q (n p U Q) O 3 a) L L U a) Q) cn C L) Z D 0) ~ 3 cv~ O LL Q N 3 ai m (n m N (n c t U) co CL a) U5 0 cO c-0 -O f- o i O= v U 0 Cli c 'a p ~ p) 7 cc C) U U CIO a U O 0 0) U) CD > .0 U) Q a d ~ pp (1) L v 0) - U) ca c C Q) C O r- O O` O ca c 1 .L ~ L- co CIJ 3 c :3 c C (n _O = ~ :3 E O O O R1 c r- ` co E- C `y c, O ca O a) O 0)~L E U v co a) a) p V a ca Q) A co -6 am c v °o 3 L) o a ''3wp ai ma)~~ a 01 N rf 0 ~ 0 a) a N O Q z O a :3 0 ca L m (z L L: O m -C -C `T C U U D) e - C n FL- U) Cl~../rJ O E c\j v7) vim) ca m ~o Q ~ o C p rvl - ~r AS BUILT SANITARY SYSTEM REPORT OWNER a I~ L TOWNSHIP 14 U A 7'1 SEC .1 7 T)_*-RIgW ADDRESS ~I' V✓ r`' ° ~t ST. CROIX COUNTY, WISCONSIN. SUBDIVISION' LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 W- EVERYTHING WITHIN 100 FE'EIT OF SYSTEM - - - - I di ate orth~A roc 4 BENCHMARK: Permanent reference Point) Describe: ° All r Elevation of vertical reference point: dG Slope at site: 7 C ~I` SEPTIC TANK: Manufacturer: W toSo^ Liquid Capacity: (G O L~ G l Number of rings on cover : Tank manhole cover elevation: Tank Inlet Elevation: 00"r6;- Tank Outlet Elevation: y, 3 PUMP CHAMBER a r Manufacturer: Nuipber of gallons A" Number of gal. pump s t or a cycle N 4 gallons; total capacity o distribution lines s gallon: size of ump /V head; gallon per minute Al A horsepower brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer ~1, Number of gallons 14114- Elevation of manhole cover Type of warning device A SEEPAGE PIT SIZE: A/ Number o pits ,4 feet diameter feet liquid depth seepage pit inlet pipe-elevation ti'/]- bottom of seepage pit elevation /4 feet. SEEPAGE BED SIZE: number of li es_ _width leitgth3-tile depth 3 SEEPAGE TRENCH: width /V length 4 PERCOLATION RATE_ AREA REQUIRED G /y AREA AS BUILT INSPECTOR DATED PLUMBER ON JOB LICENSE NUMBERS 5- 1' 3 2- L G 7 V J c0~ _ ~l ~ ~t s~ C I .17 s~ T V J ,Er ~y, trARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P,O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 KCONVENTIONAL ❑ALTERNATIVE State Plan l.D Number (II assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE. ,5,4 In Zel BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. ,V - S 4/ X/ Se c / 7 A) / uI DSO',rJ DoT /oo . Sanitary Permit Number_ Name of Plumber. MP/MPRSW No_. C DOUG sf oil t' ~y S 7~ C~~o i .~I SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV TANK OLTLET ELEV. WARNING LABEL LOCKING COVER L/ Q PROVIDED: PROVIDED ] -l dp 9 / 7/~ RYES ❑NO DYES D<NO We, e k BEDDING: VENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD PROPERTY WELL. BUILDING VENT TO FRESH L ALARM ILINE AIR INLET'. FEET FROM /-r/JQ~ ~j/ YES ONO ~"'q DYES LINO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. JLCAPACITY PUMP MODEL PUMP,SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO DYES ❑NO DYES ❑NO GALLONS PER CYCLE: 7ND CONTROLS OPERATIONAL. NUMBER OF I'Hf1PERTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE I AIR INLET PUMP ON AND OFF) DYES ❑NO INEAREST--*- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing r V TO - DIA'.11 TEH IMATI HIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: _ WIDTH LENGTH NO. OF DISTR. PIPES ACING COVER r'ID' DIA -PITS LIQUID BED/TRENCH / TRENCHE MA / PIT DEPTH DIMENSIONS /p ~jf~ff ''HAVC I I)f Pf II FILL DEPTH L UISTH. PIPE DISTR. PIPE DISTR. PIPE. MATERIAL. NO. DISTR NUMBER OF PROPE RTV WELL. BUILDING'. VENT TO FRESH BE Lt ' J 'IPI S It ABOVE COVER EFV INLET ELEV . END PIPES LINE AIR INLET. D NFEET FR EARESTOM ==Pl 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. DYES ❑NO SOIL COVER. TEXTURE PERMANENT MARKERS: OBSERVATION WELLS DYES ❑NO DYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH. BED DEPTH OF TOPSOIL SODDED SEEDED' [ULCHID CENTER EDGES DYES ❑NO DYES ENO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIi)1 H LENGTH NO. OF LATERAL SPACING. IGHAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/'TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO. DISTR. )ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. Et EV.. ELEV. CIA. ELEV. PIPES )IA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. { DYES ❑NO DYES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF (PROPERTY rLL. BUILDING. LINE FEET FROM P ❑ YES ENO ❑ YES D NO NEAREST--~I Sketch System on Retain in cou,ty file for audit. Reverse Side. SI ATU TITLE D I L H R S B D 6710 (R. 01/82) ' DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRN, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 r Attach plans for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legibly reproduction of the soil test report must be included. Pr o Owner Mailing Address: _ ~ ~f 0 wl 5 ) I t G i t / ~ l(r - T-1- O ~:c 60 k l7 Property Location: 04yTA> -i#al"Township: County: ,/J 5l. 5 ~ v1.s 17 iT )'-(~/Ni R ` At (or) 1 cc 4 Suh .5 . G r v i tC Lot Number: Blk No.: Su division Name: _ ,L Nearest Road, Lake or Lanjmark: State Plan I.D. Number: 7~ ,aek VlAly ~=5` 4fn7 fc^n i r~l' LvyA (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: U~Ki or 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY fJ t? HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit 3 C' ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Sign re: MP/MPRSW No. Phone Number: ou 1a ~f01d4beIt Z (.2~7►- y 3~3'I Plumber's Address: 1 , , / r © O Name of Designer: ~QYtt! ~ l G~ 179Gh~il W 1 ~j 7 ~ l COUNTY/DEPARTMENT USE ONLY Sin ture of Issuing Agent, Fe/e: { Date: y Sanitary Permit Number: PIPROVED l :'V Lf~t ) 1 -21o 3~C ❑ GSA PROVED Reason for Disapproval: Aiternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (6i'-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILr;R-SBD-6398 (N.03/81) NDUST E OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 'DUoTF3Y`, DIVISION • _A~OR AND PERCOLATION TESTS (115) MADISP.O. BOX ON WI 3969 iAUMAN RELATIOW' (1163.0911) & Chapter 145.045) ~ry~- LAJ~I S LOI JO ~ 7 IV INIR 9(o TO~~ IP/ o~ Y: I.: B L M. NO. S;~ I~IS~ xL✓ t`rJ//'t•T irc+.. COU TY: OWy ER'S BUYER'S NAME: MAILING A DRE$' S~- OrwAll: ?;A, /1, i/.e~ fii~~k USE DATES OBSERVATIONS MADE ~NO. BEDRMS.: COMMERCIAL DESCRIPTION: y~ D Replace DESCRIPTIONS : PERCOLATION TESTS: Residence /(,/1'7New UReplace _ 2- 'op IJ.-_ T _-4 6P RATING: S= Site suitable for system U= Site unsuitable for system 1001C ( r /Y114 4 ,/10/11 w" )01 /~ACCJ CO_NyENTIs~ MOUND: ~u IN-G® NDPREESSURE' SYSTEM IN-FIL L HOLDING TANK: RECOMMENDED SYSTEM: (optional) S U I S U='U ti' vim` r' Uti ®__l___._-__.~__.- _ SEA It Percolation Tests are NOT re wired DESIGN H f It any poi won of the rusted area is in the under s,1-163.09(5)(b), indicate: /V Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL " PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WIl H THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVES (SEE ABBRV. ON BACK.) B 3 qot. /o;'-6' ~Ww e s1, 36., 6~h /SL yJ, .5 i - ! B y lU~" /Oy -D'' /4W- /0.)'' /d f3/ S/ ♦yt s/ 10,',AI7'/S 3i~''/~►s B- ov BE A- PERCOLATION TEST., TEST DEPTH WATER IN HOLE TEST TIME DROP IN W. NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER OD _1 j>Ew o 2_ - 11E Hi r 3 t: rs iiv 11 P - • P- 1W.7 P- -.v ~„r- - - - - 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 'I0'~' UP a Q r It ~orr~ . it 3 U j -.1 +4 ti:? r iL 7, c` S fi ..n l ~ c Gn G \ 6 Q. cN s A a a ~ 01. '',i_ - 1 ~ s /a7' n l_J A, (;r een Cl! L ~t hc' / e h 4' y A4 4 r h 7L'T f o n ~ h 3. V#7htiG"( , ► ~ A L j4- - rc5 13s K, N ~i r~]tlG ! ay~~ ~ L v T t x~ r~ c c 4