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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER MA4~ TOWNSHIP ,#01pivy--' SEC. TZ~ N-R_t;7 W
ADDRESS G,v. ~tJ ST. CROIX COUNTY, WISCONSIN
Avp§.' ~V/S'
SUBDIVISION LOT / LOT SIZE
PLAN VIEW
~i
Distances and dimensions to meet requirements of H 63 foe Nk1
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
N v~G ~ME , 20 rs'r
C` ~4' Cpl
pub i ► I
b i
5 ~ I I
(pry `~5 I , ~ I
x
~b (3 0 D,po~n /30X
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used Ao1l l~~cfs
Elevation of vertical reference point: Proposed slope at site: f - ~a
SEPTIC TANK: Manufacturer: Liquid Capacity: &V -z)
Number of rings used: j Tank manhole cover elevation:
7 o'oy
Tank Inlet Elevation: Tank Outlet Elevation: y 5--3-
Number of feet from nearest Road: Fron t,9 Side 10 Rear, 0 > 02 feet
From nearest property line Front, O Side, O Rear,O /70 feet
7 /
Number of feet from: well ILO building: W
(Include this information of the above plot plan)( 2 reference dimensions to s~ntic t,lnk)
PUMP CHAMBER
e
Manufacturer: Liquid apacity:
Pump Model: Pump/Sip Manufacturer: _ Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elev ion: Gallons per cycle:
Alarm Manufact er: Alarm Switch Type:
Number of eet from nearest property line: Front, 0 Side, o Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Trench:
Bed:
Width: J~ ( Length: ✓ Number of Lines: - Area Built:
Fill depth to top of pipe: 14f+y, A
b
Number of feet from nearest property line: Front, O Side, 0 Rear, O Ft
Number of feet from well: /5 d
i
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: ameter:
Liquid depth: Otto seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacit
Number of rings us E1 ion of bottom of tank:
Elevation of inlet:
Number of 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
-2-~ b HOMES11E SEPTIC PLUMBING CU
RT. 30'NEiI RD.: HUDSON. WIS. 54016
Dated: Plumber on job: BERT ULBRICHT
WIS. MASTER PLUMBER LIC ro0.
License Number: MINN. INSTALLER & DESIGNER LIC. NO 0066
3/84:mj
DEPARTM,cNT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 79-69 , BUREAU OF PLUMBING
MP,DISON, WI 53707
13NCONVENTIONAL ❑ALTERNATIVE state Plan l.D. Number
Ilf asslgnedl
L1 Holding Tank El In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: JAD~~'S~eFPIERM'T HOLDERINSPECTION DATETom kshenmacheA ptune St., St. Pau. , MN 30 -elf
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV
NE NGI, Section 18, Lot#1, T29N-R19W, Town I Huctson
Name of Plumber. MP/MPRSW No. Coun[y Sanitary Permit Number.
Robert UtbAicht 3307 St. Croix 54918
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROM DED. PR VI PD
o +•"1 I ` ~t 3 VYES ❑NO YM ❑NO
BEDDING. VENT CIA VENT MATL HIGH WATIR NUMBER OF ROAD. PROPERTY WELL: IBUILDING. VENT TO FRESH
ALARM. / LIN LAIR INLET.
RESTOM /
❑YES O ( ❑YES ❑NO FEA
DOSING CHAMBER:
MANUFACTURER BEDDING. JLIOUIDCAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNIN LABEL LOCKING COVER
~'PROVI D. PROVDED
❑YES ❑NO ❑ S---'ONO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF FHOP V ELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LIN AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST I
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing jLEN(,TII IDIAMETEW IMA ERIAL 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 SPACINI, COVER INSIDE DIA tt PITS LIQUID
BED/TRENCH lOD TRENCHES M7RI Ir: PIT DEPTH
DIMENSIONS
G
RAVEL DEPTH FILL DEPTH 101STF PIPF DISTR. PIPE DISTR. PIPE MATERIAL' NO. DISTR. NUMBER OF PR OPERTV WELL BUILDING: VENT TO FRESH
BE LOW PIPES AB(7VE COVER EIfE;v_INLEi ELEV NO PIPES FE ET FROM (LINE'; _ AIR LET.
~ NEAREST--
MOUND SYSTEM: j
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 ❑NO
SOIL COVER TEXTURE 1PIRMANENT MARKERS - OBSERVATION WELLS
YES / ❑YES ❑NO
DEPTH OVER TRENCH BED JDEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED / SEE MULCHED
CENTER EDGES l
❑YES //LN - ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH qE LOW PIP FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATE IAL. NO. DISTR. JD~STRPIPE DISrRIBUTION PIPE MATERIAL & MARKING
ELEVELEVDIAELEVPIPES DA.:
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE.
~I O ❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on CV"' -i,cpunty file for audit. bill
Reverse Side.
URE~ _ TITLE.
DI LHR SBD 6710 (R. 01 /82)
w,scons,n APPLICATION FOR SANITARY PERMIT
.p IL H R COUNTY
(PLB 67)
V. UNIFORM SANITARY PERMIT #
DEPFIRTR L. OF ✓ y~j
InDUSTR LPBOR6HU TF1n RELFTIOnS
-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 ~j
PROPERTY O N S ~E,v~if~► MAILING ! ADDRESS
/ Al, -'-,,O F S Y G~/~ N
PROPERTY LO6.ATION CITY:
qq VILLAGE:
/V E1/4N 1/4,S ,T~/,N, RE (or (W NOF:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED 3 oav lU~1d'
X 1 or 2 Family Number of Bedrooms. Public (Specify):
THIS PERMIT IS FOR A:
KNew 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 X Seepage Trench ❑ Seepage Pit ❑ Holding Tank
LJ 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
rGallons Tanks Concrete Constructed
Septic Tank Capacity l~
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: 66- - 'wtl l t
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):
I-Or 5&Z~ l ,uc s
Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: MPRSW No.: Phone Numb r:
0
HOMESITE SEPTIC PLUMBING CO. 33 )
Plumber's Address: HUDSON; WIS. 54016 Name of Designer:
ROBERT ULBRICHT
WIS. MAS TER P1 "IMBF-A 1-113. No. 3307 M.P.R.S.
t NC. NU. NTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
Approved ❑ Owner Given Initial
0
Adverse Determination
klyn "It PA 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 i
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 PEI:MI'i'
S'1' C- 100
This application form is to be completed in full and signed by the owner(s) of the
property bt~ing 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 })i„~tt~d to this oltlce with the appropr`Late deed rreord:i.ug.
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property "I pk =sylAAAC,14
Location of Property \A.( Section T N - R W
Township t e li Mailing Address 4~p E ?-?-T _,?n.~
R'A
Subdivision Name -2*-7t p 1 G A?
Lot Number J
Previous Owner of Property
Total Size of. Parcel 4-, ~i A C- PE
Mate Parcel was Created 1~E)G 21.4, 1'2) 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 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 CERTTETCATION
I (eve) ee)t-t%6y teat aU Statenientz on thi,5 6orcm one ,tAue to the best 06 my (OWL)
hn,,wYU-dge; that I (we) am ( ~e) the own&-t(h) o6 the pnopvuty Limutibed in thin
-i.n6otcniation 4ojun, by vi tue o6 a wwvtanty deed neconded in the 066-tce o6 the
County Regi,5tcA o6 Deeds " Document No. ; and that I (we)
pnesent y own the prLoposed /site bon the eevage dispo6at 6yatem (on I (we) have
obtained an easement, to hun W~-th the above dnnibed pAopeAty, bon the
conzt,quctton o6 5aid system, and 6 same has been duty &ecoltded in the 066ice
04 tie CourI,ty RegisteA o6 Deeds, Document No. ) .
;
n
SIGNATURE CF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
APPLICATION FOR SANITARY .PERMLT
S '1' C - 100
1'hi- ~,ppIi~at iOil form i_:: te, be completed in ;ull and sigurd by thy, ()wear(s) of tit,,
propcrty bciug
developed. Any inadcquacics will Only result in delays of thk~ 0 171-tit
issuanCL'. ShOUld this dcvclupment be intended for resal-c by owner-;contr<ictor,("spec
Lwust:'yen a second form shuuLd be retained atnd complcLed when Litt, property is
SUt.I ,omiL Lud t(..) ~1e 1"1prC1p?_iri de'a'd it's,:U rt.Il:?ti.~
Owner of Property "r0 /H S ~/y~1► C -
L.ocat io11 of Property for Nw
Section W
Township ODTOAJ
Ma iILIIg A,tdress
Subdivision Name
Lot Number I - -
Previous Owner of Property W ~ I ►l`V ~ S,~~T,,,r~~J---^------`---`--
Total Size of Parcel
Date Parcel was Created
Arc.all corners and lot lines idulltifiab.lcY Yes No
Is this pr,~o~pjerty being developed for resale (spec house) _ Yes No
Volume (
-v! 0 and Page, Number /4 o +a-1 recorded with the Register of Deed_
INCLUDE WITH THIS APPLICATLON 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) ee&ti6y that "I atatcmen-td on this 6onm atte Vtue to the best o6 my (ooh)
hnowtedge; that 1 (we) am (aAe) the owner(,S) o6 the pnof-mnty d"C"t bed in this
in6onmati.on 6onm, by V-Atue o6 a wahnanty deed neconded in the 066ice o6 ,the.
County Reg is.teA o j Deedh as Document No. 3 y'S/00 arld that I (we)
pnesenUy owrt the proposed site bon the 6ewage~posctE`5y-stem (on 1 (we) have.
ob-ta,ined an easement, to nun with the above desmbed pnupeAty, bon the
eovi,st,,tucti.on o6 said system, and the Game has been duty neconded to the 0~6tc2
o6 the County Reg-is,tett o6 Deedt,,~`crls Doeumen.t No. ) .
r -
t
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
Sl'.PT LC TANK MA 1 N'LP.NANCE AGAL EMN'l i oU 1 L./ BOX NUMBI.i,. ~CQ- 1~C 1" OR~ - --54 - Fire Numbcr
e
l :~'1' is I _ _
wu n1 ~v//Sa^~ St. CruLx County,
ul ; it ~ it Lot nuill bcr
l y i s i
I
iu;f.COher use and MA11.LeRai1C, 01 Your ScpLl~ nyr;Ltww i",[:Ld rnnulL in
it , prematuru'iallnre to handle Wantc_s. Ploper IllaLnLcna"ce con-
5 L n L s o L pump Lng out the septic 1. c tank evu r y three yuars or Sooner,
11 needed, by a l ictused sups Le Laak pumper.. What you put Linn
Lhe syhtem can afKcL the tuuCtion of the septic Lank as a treat-
Mv"L Stage in Lhe waste disposal system.
St. CrOiX Count> rusLdcnLs MAI be e.iiL UIP to rucwivu a granL for
` IRax.i!ilnm ut 60Z, of the cost of repiacemcut- 01 it I;-ii l in System,
~
Wlit, h 141 in upurallotl prior Lo logy 1, L)!li- Sc. Croix County
at,j,,Led L h L s program in A " y " s t of 1980, with Lhu roquirumuut that
owuc-rs of all new stems agree co keep their systems properly
wain Lafined
Zoning a
Lihi• property uwnur agrees Lip summit to 5t. i;roi.*. l:ouuty
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper vcri--
fying; that (1) the on-site wat,tuwater disposal SysLum is in proper
operating; Condit-Lon and (2) alter inspection and pumping; (it nue-
ussary), the septic tank is leas than 1/3 lull of sLudge and scum.
Certification form will be sent approximately 30 days prior to
-L
three year expiration.
i/Wi?, the undersigned, have read the above requirement_; and agree ~
LO maintain the pi:ivate sewage disposal sysLcM in accordance with
v
the standards set forth, herein, as set by the Wisconsin Depart- ~
went of Natural_ Resources. Curri Beano" form must be completed
and returned to the St. Croix County Zoning Oltkq e w~thin 30 days ~
of the three year expiration date,
1
SIGNED
i
i
DATE
1
Sc. C -oix County Zoning; OftLCe
P.0. ,lox 95.
Nammupd, WI 54015
715-7 16-2231 or 715-425-83363
Sign, date and return to above address.
D SAFETY & BUILDING
DEPARTMENT OF REEPO T O'N SOIL., BU:LI GS AN
INDUSTRY,, m ~ c~ J~ DIVISION
LAB.M AND PERCOLATION TESTS 115 P.O. BOX 7969
HUMAN RELAT1011.> MADISON, WI 53707
(1-163.09(1) & Chapter 145.045)
LOCATION. SSE( rION O 'Nrr~i P MUNICIPALITY t_O1 Pd0 r3Lh:. NO UE2DIVIS O' %1flE
illC /NI'`}/ H/RISE() 5jy Mj7>
l OUNIY: NNl RS/fit-)YEWS UYER'S NAME (NAILING ADDRESS:
Y
='J, A! . 2,_I} 'qI -T'Tu tj
USE - - DATES MSERVATIONS 1'.1ADE _
' it0 ERCIA U f ii r1 C) f'~ rlFl f ~itlt'll,) 1~~-Tr ~v, ANON fFSi;•
RATING: S= Site suitable for system U° Site unsuitable for system
ONVENTIONAL: Im,
OU T). IN-GROUNi3PRESSURESYSTENI-)N FILI IOt DING TANK RECD",1dilENDcD SYrEM:(op:,on,li
11-Y] S ❑ I I-AS 17-lu I 1S [J 'I C]s [-]U CIS Chu 3cxZ-a ~ _,-~a~Fl~~s+~S
If Percolation Tests are NOT requi-ed DESIGN RA-1 E
11 If any portion of the tested area is in the '
lunder s.H63.09(5)(b), indicate.- - _J Floodp!ain, indicate FloodWim elevation: -
t_~ : r' 1}*/ t Z
-7 PROFILE DESCRIPTIONS t
PORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL VVI fH THICKNESS, COLOR, TEXTURE, r~~lf? DEPTH
NUMBER DEPTH IN, ELEVATION O_BSERVEU EST. HIGhiESr TO BEDROCK fF OBSERVED (SEE AHBRV. ON BACK.)
Eev PERCOLATION TESTS - ~(1 S=-~ H
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MIq UTES
NUMBER liv #ES AFTERSVJELUNG INTERVAL-4,11N. PER I f' 1-I
11
_PER10D2 PINRICY~3___
P-
P:-- -
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate sc_I, or r:i;taoces. Describe what aie the hoti-
,ontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation me all brrrsnes and the direction and percent
of land slope.
SaUTl4t`=,hSi°.~ GM 34
SYSTEM ELEVAT !ON 3
i .
•
I
i
i
i
I, the undersigned, hereby certify that the soil tests reported on this form were made by rile in accord with the procedures and method; sp-rcififzi iin the Wiscon;ia
,?dministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
i•lAPAG (print): TESTS VVFHE CODIIPLETED ON:---~- - j
-J A;: t1A E
ADDRESS: - CERTIFICATIONNU,14BER: PHONEWMBER(option-il):
r
1----- Z = u- r> - f~ S v % L 1C ! I J C j 3 -
- - CST ;176NA rURE - -
DISTRIBUTION: Original and one copy to Local Authority, Property O,"iner and Soil Tester. `J
1IR-SB0-4,3395 (R. OVER -
DEPARTMENT OF REPORT' ON SOIL WRINGS AND SAFETY Yx BUILDINGS
INGUST..RY, AND DIVISION
LAUOR AND C{~ TESTS P.O. BOY, 7069
fIU,*AN RELATIONS P OLATION ^~~-STS (115) MADISON, 1,^.rl 53707
4P o L (1-163.090) & Chapter 145.045)
Il_OCA"FION: Sc CTIO\ FOIVfJ tIIPI UNICIPAI ITY- -ft_OT SUBDIV,: 1C;J rtiA".1E---'---
t~I H/11 E ( 1 D o
t r E 1 P_ J, l" I~j~ !3
prl j 1 1 1 F-T
01 ~(T(' N ri S,Bl)~YE~Fi~SiAIti1E ~ ~ i,1F911 I!
, 11GA[
I /1 ' [~j')FtE55
G' k
DATES 031"ERVALIO S MAD
~CC1„
1c I L U Cr I' -
~PF J IL E C~c :3t(10:, 5 r'c C;rl 10 l
RATING: S= Site sritah'e for system U=- Site unsuitable for system
I OVVcNI-IONAL. ,:1)U D. hNGROUti1FRcS ZE SYS7EPr1-IN FILL IOt.DI GTANK tiECOP'"cNJ 6SVc;1 E1lobiOu.1
- - a
~le Percolation T any
ts arE ) rcyulred 1 DESIGN RA IF,e the
s.H63(e51(b1,1
Floodplaln, indicate FtocJ - anon .
PROFILE DESCRIPTIONS -;r• ' i 13U 2K{ fit
TI
ic C)RING TOTAL DEPTH T O GF OIJND!^JATEFi IVCNES CHAPACTER OF SOIL WITH TLSICKFdt SS, COLOR, TE TL :E,
Jt1^ER DcPIHtRLtLEVAON OBSERVED EST. HIGHEST TO REDROCK IF OBSERVED (S'" Ao ERV.OriN BACK;-)
B' . ~~t t 1 (3, L~ 'i1EC- C.S
o "i
'AL
3.7S' c-, Sr l_j °>O' UN I.LC)+ Qr
B gn ° . t _ v } -,.a' r c r./ J (r • l
1 mot-- I-i t Sr,) L- ` J 5,oo' ISrJ i,.e=T? 5 i>:Y-zC r
I P- I-- - - __-tom. r7_~ ; L < ~ - f ~:1 r- . - ~ - - - -
SU n L ~S/J 1~n! r^/U / :r`_ , 3.501' c, 1c.PlJi,Trs 7
PERCOLATION 1:E5TS - ~
TcST DEPTH N1A TER IN HOLE TEST TIME P~J I Jq~Ekt~r~y rr~c MU r rc`- _ t
NUMBER INC--HcS AFTERS.'JELLING INTERVAL-MIN. F; ATE t Ialp cr y p ~tjpp2 -t - PFF INC 1 [I_
lAI4-i
;
PL-OT PLAN: Show locations of percolation tests, soil boring; and the dimensions of suitable soil areas. d .;tant:es. D.,scl ibe whir are the hori.
zontal and vertical elevation reference points and show their location on the plot plan. Shoo, the s_rface c vatic a!. and tha dire•rtiw-i and percent
of land slope. 'rC..:
SYSTEM ELEVATION
,
l
\POf`/D
t 6.rB
, ~ ~S ~ 'I rr vie FAFc~/
Jo PARK C -_n - °
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13 G,E/ ~MLiv LNii _
NOR~T}.
'HUDSON
I
f, the undersigned, hereby certify that the soil tests reported on this form were rnade by me in accord with the proce&jres an:l msthnds s; e, il"'orl in tha ClisconSi-,
Administrative Cade, and thJi ttr cal.: recOrd»d zr!,d of th,• tests are correct to the b^st of my h.r !cd_;c ,,r,~i L, !jet.
i rLA^I E (print): IFS[ 4Vt~{t C0 .1'I_rl L1) Ui~: q
ADDRESS - - - L-------
l ! r r:ERTIFICATION NUMBER: [1>1-10^;E NUMBER(option,,&:
CST SIGNATURE:
DISTRIBUTION.- Original and one copy to Local Authority, Property Owner and Soil Tester,
O i L f-I R.
SBD 6395 iR.02f82i OVER
4 r 1
REP
Wr OF REPORT IL BORINGS A~ SAFETY 8cEUILDII`dGS
Y, e ~ D DIVISIO;j
AND _ PERCOLATION TESTS 115 P-0. 13OX 70f7:
,N REC-Al-IONS MADISON,VvI 531(4-4
• / or (163':00) & Chapter 145.045)
~ OL~'i~SFiIP~N1UNICIPALITY: LOT VO. BI_K. NO UdDIVISIO^J f~FME t
N~ 1/4N\.)/`1 1 ITz-9 Nf l°)E f ' - cfy75c~rJ I -
COUNTY: n Ni WSIBUYEH'S NAME: 1AILING ADDRk Ss -
r . nn
['SE DA rFS' O i _RVAT10NS f1ADE
- - o, ~Vl
5.: C ) ,V1EFt IN! I) C{;l'LIU.;' I i0rILY FI0r_,j: r cRC )L i1r
1 ,_i t itl :c ~ I LiNew ~ _IHEF~I L
RATING: S° Site suitable for system U= Site unsuitable for system 1
- -
S U
O"JVENTlZ)NAl : F. C)l~~:l% IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDIN -G-TA-NK-: HECO'v11VIcNDED SYrTEP':loF~bonal)
Ii Percolation Tests are fJOT required ~ESIGN RArE: - If any portion of the tested area isi.n the--
unders.1-163.09(5)0b0, inciic„te: Floodplain, indicate Floodplain eleratic:ri:
PROFILE DESCRIPTIONS
BORINGi TOTAL DEPTH TO GROUND\^JATER-INCHES CHARACTER OF SOIL V ITH THICKNESS, 4:OLOR, TEXTURE, fvwD DEPTH
NUMBER DEPTH-tN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED ISEE AB6RV. GN BACK.)
o . 7 U ' qtr t_. , t7. g ,v N! p S .
E3 53 4-0,
JN £ C j
B j 3. S U' i r: 1e,1 = Z, J l S V"6 rZ
Ip_/ pJ ' t ~lC~r1 r -3.0°. O. So L 4 SU' /✓t~'~ 'J.OS lZ~l Se
i
i I
PERCOLATION TESTS
C- TC~ a DEPTH VIATFR IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATF f ITl TJ 1 GS -
P•;i iT t 1~ INC.HES AFTEH StVEL1_ING INTERVAL-MIN. PERIOD 7 PERIOD 2 I- RIUD PER INCE:I
t'-
r
")T PLAN: Shwv,, locations of percolation tests, soil borings and the dimensions of suitable soil areas, lndica-e scale or dista:_,<_- Describe what arz- the hc,
;ont:,1 and vertical elevation reference points and show their location on the plot plan, Show the surface elevation at all borir"I and the direction an•d percent
land slope.
it EI EV TIT
•
r I
I
,
i
i i
i, the uodeisigned, hereby c-,r tify that the soil tests reported an this fora, were rnada by me i,i ace.urd with the proced c-is and method; cracifirzf lin t) `kdisransin
Adrninistrative Code, and that the data recorded and th=; Iocatir->n of the tests are correct to the b- t of my knovvh~t!ye iw.l ts~L- f.
dAME (print): TESTS WERE COMPLETED ON:
i
:JIUDRESS: CERTIFICATION NUMBER: PHONE NI.IMBER(optional):
CS"r r NATURE:
i)ISTRINLI ;ON: Oeikginal and one copy to Loci it Authority, Property Owner and Soil Tester.
k-:1 t tics e.nr~ i+nnr__ "'3-
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/ RT. 3 O'NEiL RD., HJUDSAN, WIS. 54016
,G OC~~ ~ (ROBERT ULDNCHT t
~MINN. INSWLER R DESIGNER LIG. NO. 0006",
6/
Fresh U Inlets And Observotion Pipe.
Swsi~. Tf- 5T'a F~ i3y
klom ;sln "ors G x:G. k z:provod gent Cop
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a .t d r r Minlrnun-12" Above
Final Grade,
4" Cast Iron
~f L Above Pipe - -
Vent Pipe
io Fincsl Grade
;()i L Marsh Nay Or Synthetic Covering
min. 2" Aggregate
Over Pipe
1 Distribution a- Tee
FT, Pipe 0 0 0 0 0
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3 Aggregate 0 Perforated Pipe Below
Beneath Pipe
0 Coupling Terminating At
a 1r3 T e R 0 t t o M )f .S stem
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pE,p So%~ ~S~ PLO- r and eR 055
SRri o N PLANS
5-/E,,!~L f. (X- 10017'
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L~cEtisE 330 7
Fresh Air Inlets And Observation Pipe
SOIL. TE S7'r,. 13y
MOMi51TE TESi'NG d-
G.
RT.,3, 4%'lle,i Approved Vent Cap
HUDSON, WIS. 1-4016 Minimum 12" Above
Final Grade
M~~;~vM a~ ~ f.
Above Pipe _ 4" Cast Iron
7o Final Grade Vent Pipe
Marsh Hay Or Synthetic Covering
`Min. 2' 1 Aggregate
Distribution Over Pipe
Ow" Pipe 0 0 0 0 0 Tee
T~sr
S11~L Aggregate 0 Perforated Pipe Below
Beneath Pipe
o Coupling Terminating At
Bottom Of Sstem
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