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HomeMy WebLinkAbout161-1021-95-000 o N O 3 v 0 r~ O " m O `r1 c O O CD CD -a v 71 o - C CD \ 1 3 j~ o N N D O c 03 CD I (D d~ Z d~ N (O ~ I CD N~ ~ 1 m Co r o o O (D fy N >v N ;A O -0 Q 7 Q (D p (OT cn o C: CD ;1 6 2: C.n 3 Q° o ° C5 O 3 rn Ct) N C 2 0) N C Z 0) C (D CD CL N Cl) > (D Q) j (D c a w o g + 3 p W CD ° aOi r`~~y] C t~ L.7~ L A N f~'1• O A A CL N O C !V Q Z -0 S H r m m m 2 li v !V• z 0 0 O v ~p G7 C Ul r- o Q C: a a ti rn m Z - v Q O O W N PK" (l (D fn 7 d ~1 M 'a Cn CD o c D CD 0- T 7 m a CD 3 rn N -i Ul r o z Co z r n D a ~ r lye v O ~ Ri I, 7r\ p' lV d oo' m y t~ (D C 1 N. C C) N (O Q w (D CL I c n 3 CD --I ?y Z O A Z A O in C .n+ C -p r n A Z O 7~ v a O 3 W O w Z C, 3 o _ D A O .r N rv 3 Z CD N a O Q C O < (D O i tll z O. ~ O I N O (n N A X C) Z Q Q d A fi N W I N O O a A N i O _ b i (D it N (Jd O N O CD -0 0 i Parcel 161-1021-95-000 06/23/2006 12:35 PM PAGE 1 OF 1 Alt. Parcel M 13.29.20.405.406 161 - VILLAGE OF NORTH HUDSON 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 - OLCHEFSKI, JAMES D JAMES D OLCHEFSKI 631 GALAHAD RD N HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 631 GALAHAD RD N SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.000 Plat: 02/35-LAKESIDE ADDN 1910 LOTS 5, & 6 BLK 4, & PT VA- CATED 4TH ST Block/Condo Bldg: LAKESIDE ADD VIL NH Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-29N-20W Notes: Parcel History: Date Doc # Vol/Page Type 03/16/2004 756789 2527/490 WD 09/29/2003 741681 2421/554 PR 1060/587 QC 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/22/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 348,500 356,500 705,000 NO 02 Totals for 2006: General Property 0.000 348,500 356,500 705,000 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 348,500 326,500 675,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 310 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT ~l OWNER (l (J / L 1~ X0k UG~fm SEC. T N-R W ~o D 1` L ADDRESS ST. CROIX COUNTY, WISCONSIN Z/- / L tX SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~I uJ I 2~/ y o `z -I I i _y ~ I Ih .fo u to r 36P ~y . Giwc - ~ ~svRr~~ ya/~ ~ INDICATE NORTH ARROW -7olp d) Oc I!ld 1S BENCHMARK.: Describe the vertical reference point used D.y G O J` Gi'vg fT. Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK:: Manufacturer: _~)a~~/~f (-6~• Liquid Capacity: • Number of rings used: 6 `rank manhole cover elevation: Iy y° 7z.1 ' Tank Inlet Elevation: q L ~ 4 Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side, 0 Rear, O > a G G feet !1 . j;'rom nearest property line Front,0 Side,O Rear, O ~7 7 feet Number of feet from: well 1 / building: / (Include this information of the above plot plan)( 2 reference dimensions to scl)Lic tank) SITE I~I~:VI?IZSF'. 5ll)I: PUMP CHAMBIrR 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: larm 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: y Length: 3 Number of Lines: Area Built: Fill depth to top of pipe. )n'4X- Number of feet from nearest property line: Front, O Side, O Rear, O Ft ' Number of feet from well: ' /00. O c7- / / Number of feet from building: J (Include distances on plot plan). SEEPAGE PIT i Size: Num e its- Diameter: Liquid depth: Bottom of seepage p eevation: Area Builtpt: Has either a drop bw n or Ji-lk-rion box 0 been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: pa city: Number of rings used: Elevation bottom of tank: Elevation of et: i Number'of feet from nearest property line: Front, O Side, 0 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 H / job: HOMESITE SEPTIC PL l~MBING CO. IT. 3 O'NEIL RD.; HUDSON; WIS. 54016 License Number: ROBERT ULBRICHT W. MAWR PLUMBbR He. NO. 3307 M.R.R.S. MINN. INSTALLER & DESIGNER LIC. NO. 00663 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN 41ELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX iy69 BUREAU OF PLUMBING MADISON, WI 53707 IX CONVENTIONAL ❑ALTERNATIVE State Pia, I.D. Number ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Ilrasslq,edl NAME OF PERMIT HOLDER: [ADDRESS OF PERMIT HOLDERINSPECTION DATEL. G. GitbetLt 7th St., Hudson, w1 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PL ELEV Gov't. Lat# 1,Secti on 14, T29N-R20W, Vittage vb N. Hudson Name of Plu be, MP/MPRSW No. 7o,r,iy. San1[ary Permi[ Nu tuber. Robetut U,2bt icht 3307 St. Ct oix 49489 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY. TANK INLET r~LE V.. TANK OUTLET ELE V.. JWI G LABEL J LOCKING.CO cc I / OED. PROVID ttl..aii YES ONO ❑ NO BEDDINGHIGH WATER NUMBER OF ROADPROPERTY 1BUILDINPU VE TO FRESH ALARM FEET FRO20 LAIRIN LETDYES OYES ONO NEARDOSING MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMPISIPHON M UFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED'. DYES ONO DYES ONO EYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. %NO PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN RO NF IAIR IN LET PUMP ON AND OFF) DYES ONO REST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing II DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until F R E the soil is dry enough to continue.) AI CONVENTIONAL SYSTEM: BED/TRENCH WIDTH. L i"q TH NO. OF DISTR. PIPE SPAC]' covE JINSIDE DIA at PITS uOUIU DIMENSIONS !(I TRENCHES & / M IAL' P DEPTH GRAVEL DEPTH FILL DEPT DISTR. PI F DISTR. PIPE DISTR. PIPE MATERIAL. N DIS NUMBS OF PROPERTY WELL. BUILDING. VENT TO FRESH I LINE. 'ENT BELOW PIPES ABOVE COVER ELEV LET EV. ENS PIPES FEET FROM L/- NEAREST -s-/av c 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- DYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSEH VA TION WELLS OYES ONO DYES ONO DEPTH OV EH 7RENCH:BED DEPTH OVER TRENCH.' BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES ONO DYES DNO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVEH BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE. JMANIFOLD MATERIAL. NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV.. DIA. ELEV.. ' IPEs . CIA DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY^ MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED /V PLANS DYE I ONO EYES ONO COMMENTS: PERMANENT MARKERS: OBSE LS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE'. EYES ONO DYES ONO NEAREST ~S -7 1 V Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. DILHR SBD 6710 (R. 01/82) FITLE ~~,wlsconsln APPLICATION FOR SANITARY PERMIT COUNTY ILHR (PLB 67) - UNIFORM SANITARY PERMIT # ~ DEPRRTTEnT OF ~ InOUSTRY. LR9014 6 HUMAn RELRTIOnS xn V -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 . G - 61,1- 13zX T /0 2 0 7 H' S-f - f 1`910 .(1, curs , s" yon PROPERTY LOCf\TION CITY'. vD fQ~ Q,rO(, r )-or I VILLAGE: IV(Vf~ 1 /4 1 /4, S T' N, R ~O E (o r W romrtweF : LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 1600'r.401# / pGif- 9F (9,4 /A' 44,0 . TYPE OF BUILDING OR USE SERVED )A] 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A: X 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. 4 Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holdiny 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 IV Manufacturer: E~'/C S OA. 060 0N 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): PROPOSE (Square Feet): 3. S F.2-0 F6 )y 3 6, )L 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: PdW/MPRSW No.: Phone Numb r: HOMESI 330 1115' 1 ' jpy Plumber's Kfi4ityNEIL RD., HUDSDN, WIS. 41U. Name of Designer: ROBERT ULBRICHT & DESIGNER LIC, ND. OQ5&' COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ¢L' ~j~/ ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILAR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber i r 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. r r, v, c: ' ST C- 105 r r; SEPT LC TANK MAINTENANCE ACRLI:MEN'1' 0 St. Uroix County t)WN 1': I(/ li U 1" t': IC ~.--~___11:/-,F-C~F••l_~' ~l~'~C~C,,.`.<--~" --~/~~~~'r~ in Rt)LlTE/bUa NllMBER I'-ire Number CITY/•` T X T L: Se t i n N , l 5 t. C r, i CO U n i L y, SubdivLsiun Lot number. .0~41c/fe'7deccul~di host= l Improper une and maiut.unaocc of your bcpt-i, :system could resulL in i t s p r e m a t u r e l a l l u r e to h o H d L c wastes. K o p e r M a i n t e n a n c e con - si5Ls of pumping out. the septic Lank cvwry three yutars or sooner, it nuuded, by A I icunn d sr t,L is t..auk hunpri . What you put into the system can a 1ecL Lhe 1unctinn of the ncptis tank as a Lreat- went stage an the waste dl5posal system. St. Croix County residents nuiY be uLigiblc to receive a grunt for a maximum of bUZ of the cost of rupLacemenL of a failing system, which war; in operation prior to July 1, 1 JH. St. Croix County accepLed thin program in A"pust of 198D, with the rcyui-rcment that owners of All new sysLemn "preu to keep ih. it systems properly leaLnLained. Thu pr"parLy owner agrees to SnbmLL to AL. UroLx County Zoning a curt i f icaL inn turns, signed by Lhe owner and by a master plumber, journeyman plumber, reslritt_cd plumber or licensed pumper vurL- Eying, that (1) the on-site wastewater disposaL system is in proper operating condition and (2) after Lnspection and lumping, (if ucc-- essary), the bupl-ic tank is less than 1-/1 lull of sludge and scum. Certification forth will he seat approximately 30 days prior to 0 three year expiration. 0 1/WE, the undersigned, have read the above requirements and agree u, to mainrai" the private sewage disposal. system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- It went of Natural Resources. Certiticatiuu form must be =ompLuLed and returned Lu the Sc. Croix CouuLy Z"ni.trg Ulfi-ce withLu 30 days of th three year expiratiota date. S I CN1~ St. Croix County Zoning Ol I ice P.O. Box 8 Ilamnu nd, WE 5401.5 11 5-', 96-2-1 3 1 or 715-425-13363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT S '1, 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/contractgr,("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 Qe4¢ Section T9 N - R W Township I/ice Mailing Address -z~ Subdivision Name Lot Number , fj tv ~<r~ f~'f_-rtes if- Previous Owner of Property /ZCl/~ Q' cao~~~ czc/ r Total Size of Parcel 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 c as recorded with the Register of Deeds INCLUDE WITH THIS APP-L-I~C_A.rrION ONE OF THE FOLLOWING : 1. Warranty Deed 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 1 (We) eeAti6y that at .5tatemen.t5 on .th,is 6on.m an.e thue to the beet o6 my (otUt) know edge; Aa,t 1 (we) am (aqz) the owne,lL (e) o6 the pnopehty descAibed in .thi,6 ,in6onmation ;6onm, by vigtue ob a wcmanty deed ~tecottded in the 066ice 06 the County Re.gi,6 teh o6 Deeds as Document No. I-- and that I (we) pnaerWy oan the phoposed site 6m. the sewage Lapos system (oh 1 (we) have obtained an ecusement, to nun tcLth the above de~snr bed pnopen-ty, 6on the consttuctiov, o6 6a d system, and the same has been duty n.eeonded in the 066-ice o6 the Counay Re9i,5.ten o6 Deeds, as Doewnent No. ' SIG GF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNtD DRTMENTOF IN REPORT ON SOIL BORINGS AND /VI SAFEI Y&~JBUILDINGS ~ INDUSTRY, DIVISION ANU TESTS (115) P.O. BOX 7969 R+~LATIONS PERCOLATION HUMAN , MADISON, WI 53707 ,,o u, Lor/ (H63.090) & Chapter 145.045) LOCATION SECTI N7---- lUWN EiIP/MUNICIPALITY E-OT :f31_K NO.: SUBDIVISION NAM EM ) I /T ,9 N/R 20E d ti~ av5 off" ~ES~1~E COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: z; S .mod/ L . CG . ~3 r /O~ G? 77f- S~ . llu©So,o CUBS USE DATES OBSERVATIONS MADE NO. rryy-~ BEDRMS. (OIVINIERCIAL DESCRIPTION: ~~r} PROFILE3TtONS: P~RCAT10 I~TESTS CJResidence New i _ Replace RATING: S= Site suitable for system Jod FCC s7 11u hh -,2t) U= Site unsuitable for system ONVENTIONAL iNOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FILLH0LDING TANK: RECOMMENDED SYSTEM: (optional) S ❑ U ❑ U _ N S ❑ U ❑ S [4 ❑ S ®U C'a vvE,~Tio cJ / o oe 71(c' ,v If Percolation Tests are NOT required DESIGN RATE: If an y portion of the testd e area is in the `C~-- under .N63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: r',< /.V DECfM/41 F'l• PROFILE DESCRIPTIONS BORING 'TOTAL DEPTH F..LEVATION DEPTH TO ROUNUWATER-IN - CHARACTER OF SOIL. WITH THICKNESS COLOR, TEXTURE, ANU NUMBER DEPTH OBSEF~VED_ _ E_IFIIGEiF;;T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK,) B- sP alr3u.S 1,,P3' :is s -a s, s' f, l Q.0' /o0.( - Ak Is, 3~'vEa ,S- B- 2- P0 /00. le , fro > j? o .33 AL - ~4. Is ~ . y2 ' /3ti. is) / .7 s 3 0 0 AJ. /s 6.0f' ~~Q v ~awt s e /s wry tt ~a-G~ ' /0 / Z - 5 ' /~(/3a . TS 8,v . /s, i op Q v raw~~'. LB o a, B- 5 d /oo, 5-3 > - .y z au. Is y R-, IS, 2~RA.,P- V"~ 411 B- i . PERCOLATION TESTS _ TEST DEPTH WATER IN HOLE TEST TIME DROP IN WA TER L FVE'L INCITES RATE MINUTES NUMBER IN AFTERSW'ELL ING INTERVAL_ MIN. pE~flpc~ ~3T15f~'f PER INCH 3 0 ` P- 1 . J -2 P_ c P- 2- PLOT PLAN: Show locations of peicvlaUon tests, soil borings and the dimensions of suitable soil areas. Indicate scaly, or distances. Describe what are the hors 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. / /0 6F l3A~Q a~' /.C'P,if gcTGy SYSTEM ELEVATION . 0' l4 w ve'e FT Y , r,pa y~ /,z p =x r 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 t 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): Yt.l I TESTS WERE COMPLETED ON - - It FATE APPRs " ' ",S" ; d ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional) t w7 4 5-~J _`YC....gyp. ✓ S^ L J yA ~"/v CST SIGNATURE #.I t ~ DISTRIBUTION: Original and one i.;opy to Local Authority, Property Owner and Soil Tester. f QILHR SBD-6395 (R. 02/82) OVER . aP~C'~tT ON SOIL C~URIN GS PERCOLATION TESTS J IS- PIVT 66U-7- ~o f / SEc. i~ Pc.oT PLAN L PROTECT r. D. T y HOMEc,iTE TESTING co. (3 O'MEIL ROAD BOB wUSONt WIS..... 540I6 C5T S3- 02 yeZ PROPOSED ii&jsE moss LIE' 2~ Fr. 04 A10, F , OAl ,gLc TEST fl,PEAS. PROPOSED We a M VST LIE .SQ Fr O,~ ~DiQE FiPOH A~~ TEsT ~q,PE'.fs, • = ~3At~iyoE P~Ts = zr/sri.v !r- W ELL X = PE~c ~oc•~r~ow,t = yAuP Av~E~FO o,~ s~ovEC /.3gr,Fs • hIrwiz . 13M VERrICAL REFERE/vc,r p61;07- T p SLOT G%.V E o T /AJ4 nJf LEGENp /Ere~row o,~ !/,F.,Pt' /PE'F. f T . O r r r Al f r , V ~ ~ o ► I VER (32- 131 pt~f . I It D,J i P1 PLOT and 055 5-64 3d SEcTjoN PIANS 35 fr. 6 ti 7/3 f3 z i - igT r"r r^,Foo~~ 10i'0 J E67 G 115, So . -ScP4 Or- -T ©60 A/ bD - s ? P 17, -etc toill Fresh Air Inlets And Observation Pipe SOIL TE5T055 13y EJOM SiT6 TES s 1G +C3o Approved Vent i;-) RT.3, O'WE;L RO'N HUDSON, Wis. ~a4016 Minimum 12" Above Final Grade 4" Fast Iron ~1- Above Pipe Vent Pipe To Final Grade f ~I Marsh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe ~sviL Distribution Tee ~ SSA Pipe . 0 0 0 0 0 rte' ( " Aggregate 0 Beneath Pipe Perforated Pipe Below 0 Coupling Terminating At Bottom Of System