HomeMy WebLinkAbout022-1002-60-001
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Parcel 022-1002-60-001 01/31/2007 08:24 AM
PAGE 1 OF 1
Alt. Parcel 2.28.18.20D 022 - TOWN OF KINNICKINNIC
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
DANIEL R & TAMELA SIMONSON O - SIMONSON, DANIEL R & TAMELA
570 HIGHLAND RD
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 570 HIGHLAND RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.920 Plat: N/A-NOT AVAILABLE
SEC 2 T28N R18W LOT 1 OF CSM 5/1427 Block/Condo Bldg:
695/327
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
02-28N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 695/327
I
2006 SUMMARY Bill M Fair Market Value: Assessed with:
178508 329,300
Valuations: Last Changed: 08/10/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.920 60,000 244,000 304,000 NO
Totals for 2006:
General Property 2.920 60,000 244,000 304,000
Woodland 0.000 0 0
Totals for 2005:
General Property 2.920 60,000 244,000 304,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 557
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
s
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T -N-R W
ADDRESS PIS=' COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW WITHIN 100 FEET OF SYSTEM
t
IT
r/
r'
n, t
i
i
3
L
I di a e oth Arrow
SCALt: - -F ; -
BENCHMARK: (Permanent reference Point) Describe
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings on cover Tank manhole cover elevation: Ia
Tank Inlet Elevation: 1/? , Tl t Tank Outlet Elevation: )I)• P
PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set or a cycle gallons; total capacity o
distribution lines gallon:. size o pump head;
gallon per minute horsepower ran name of pump
and model number ;
Type of warning evice
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: um er o pits feet i.ameter
feet liquid dept seepage pit in et pipe-elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number cf lines, width length tile depth
SEEPAGE TRENCH: width length `
PERCOLATION RATE AREA REQUIRED AREA AS BUILT
HLPADER.LINE ELEVATION DIST. PIPE ELEV. INLET - ELEV. ENDV
DATED PLUMBER ON JOB
LICENSE NUMBER
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX77969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MADISON,tNl 53707
MCONVENTIONAL DALTERNATIVE State Plan I D. Number.
Holding Tank 1:1 In-Ground Pressure ❑ Mound (If ass ign ed )
NAME O:FP ERMIT HO LDEH: ADDRESS OF PERMIT HO LDER. INSPECTION D TE.
Dan Simonson R. R. 1, Roberts, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.
SE NE, Section 2, T28N-R18W, Town of Kinnickinnic
Name of Plumber. MP/MPRSW No. County Sanitary Permit Number:
Eugene Grove 5569 St. Croix 54955
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
PROVIDED: PROV,ID
U YES ONO D1EQ
~ NO
BEDDING. VENT DIA ~ ~T-. HIGH WATER NUMBER OF ROAD: PR OPERTV =LBUILDING VENTTO FRESH
ALAEET FROM LINE
❑AIR INLET
YES NO EAREST DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMPiSfPHON MANUF ACTUREH WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
DYES ONO DYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET'
PUMP ON AND OFF) OYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing NGIH DIAMETER 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:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVER NSIUE DIA tPITS LIQUID
C. TRE~HES MATE PIT DEPTH.
DIMENSIONS LI,! Lam"
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BE LOW PIPES ABOVE COV Epf ELEV. INLFI ELEV. END PIPES FEET FROM iLINE t / AIR INLET.
(-e L Z Z NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
D YES O NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ONO DYES ONO
DEPTH OVER THENCH'BED DEPTH OVE R TRENCH.' BED DEPTH OF TOPSOIL SODDED SEEDED jiULCHED
CENTER EDGES
DYES ONO DYES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SP~JMA RW PIPE FILL DEPTH ABOVE COVER
TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE NIO DISTR. JDIA
E ISTR. PIPEDISTRIBUTION PIPE MATERIAL & MARKING
LEV. ELEVDIA ELEV.PIPES
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DHILLED CORRECTLY ATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
DYES NO COVER M PLANS DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
❑ YES El NO ❑ YES ❑ NO NEAREST
Sketch System on R.P-4-'in county file for audit.
Reverse Side. _ 9
SIGNATURE ~ ]TITLE. -
DILHR SBD 6710 (R. 01/82) '
® wlsconsln APPLICATION FOR SANITARY PERMIT L
COUNTY
,,D I LHR
oEaRRTmenT OC (PLB 67) UNIFORM SANITARY PERMIT #
InOUSTRV, LRBOR 6 HumRn RELRTIOnS _
Ts 5
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
7S 1 ir Al er t Xe M,= i 5 . k1. ;S,-Kez
PROPERTY LOCATION Cam;
VttlzAa :
1/4 1/4, S , T.~b, N, R ,/,A E (or) TOWN OF LOT NUMBER JBLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
A IM /V 4 4( 1 X73 /~/f
TYPE OF BUILDING OR USE SERVED oaa `G/Up2
✓1_1 or 2 Family Number of Bedrooms. ❑ Pu" blic (Specify): IV14 15 THIS PERMIT IS FOR A:
EP,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.
El Seepage Bed 1 J 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
❑ 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 /47-c- i~
Lift Pump Tank/Siphon Chamber .14
Holding Tank capacity
Manufacturer: 3 - S
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
e 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):
3ey er w Tre-, 14' [ 'Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the privates . age system shown on the attached plans.
Name of Plumber (Print): Signature: MP/MPRSW No. Phone Number:
Plumber's Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
. s ❑ Owner Given Initial
I ~`d Approved
Adverse Determination
Jk/Ltau
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 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 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 y ~C Q00241,1y.y-J
Location of Property ;a[~ Section,-, T '70 N - R W
Township
Mailing Address
Subdivision Name
Lot Number
Previous Owner of Property
n
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
c
Volume 1Q /,/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 CERTIFICATION
1 (A) eentily that al 6tatemen.tt un tiu:6 loom ate Aue to the befit of my (out)
kHow edge; that 1 (we) am (ate) the uwneAQ of the pnopen,ty de,enLbed in ,thin
k6onmation loam, by vixtue of a watanty deed neeonded in the 066 ice 06 the
County ReQtu of Deedt at Vocarnent Nu. -3y5i j ; and that I (we)
pnete.nt('.y own the proposed ~~te. loo the 6ewa'9(c ( o.aa~ system (on I (we) have
obtained an qa umunt, to run with the above desav bed pnoputy, {on the
con6tn.uct(on o{ Laid Aybtem, anI the tame hat been duty neeonded in the 016,tce
u6 the County Regi-ten o A Deeds, at Document No. ) .
f
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
1)V1 SIG ED DATE SIGNED
H
S T C - 105 r
r
ti
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County ~2.
U
y
00
OWNER / li U Y E R r olttL r- _ / / r
l -
ROUTE/ BOX NUMBER Fire Number
CITY/5TATi?/`- f Ge l !.l1 -
PRUPERTY LOCA`1'ION:~~~~__~4, ~ SUCLi-on T_ N~ RJ10 __W>
T own oiSt. Croix County
Subdivision Lot number
I
Improper use-and maintenance of your septic system could result in
LLs 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 stpt-ic t_r11 f~um1er. What you pert into
the system can affect Ch, function of the septic tank as a treat-
went stage in the waste disposal sySLem.
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, resLricLed plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating; condition and (2) alter inspection and pumping; (if nec-
essary), the Septic tank is less Clean 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiraLLon.
0
l/WE, the undersigned, have, read the above requirements and agree
Lo maintain the private sewage disposal system in accordance with ~
the standards set forth, herein, as set by the Wisconsin Depart- to
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.
i
~YL~-✓
SIGNED
DAlh
~I
St. Croix County Zoning Office
P.O. Box 93
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
SANITARY PERMIT LJILHR
County
---~`(•^MnT C GROUNDWATER SURCHARGE
i r~u~cw,~s~soncrKxiwns+e~wt~orn Sanitary Permit No.
I
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly known as the groundwater protection law. This change in statutes was the result of over
2 years of steady negotiation and public debate. The groundwater bill included the creation of
surcharges (fees) for a number of regulated practices which can effect groundwater. The
surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to
the groundwater through your soil absorption system or the disposal site used by your holding
tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
Ground >It*r "
Signs re of Issuing A ant: Groundwater Fee: Date: WISCO $ltl'it
y r ej buried treasure
DILHR SBD-7289 IN. 05/84) s
i
DEPARTMENT OF
I REPORT ON SOIL BORINGS A~VFETY & BUILDINGS
INDUSTRY, CF' DIVISION
LABOR AN4 G ~ R.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115). `'1(/IADISpN, WI 53707
• (H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/#} LOT NO.:B K.NO.:SU DI VISIONhfAN
5E WE 1/4 1/4 Z 1T28N1R /8E (or W
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
ST. (f)? o i X ~f~ 'J S / t t? A~ t' /V • }
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
1xResidence New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: lGROUN PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
~s ❑u as [Z Ds au ❑s 21,U
❑s Wu
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATERA? CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH+N- ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
L S r'Ps 'off; u
B) - 92. 4 /V 0 iv E 3 0. s' 6„ -Fs s R CD 4-. o' r
5
9Z. Al 0 A,1 i DKGy,B~ sc~Ts, Z.Z' t3nS/, /,3~ ~
B- 7
A 'n°i a rr O. 3 Cr3 n s L 't' S jc2L q u DkGy. Bn sc/
0 /U
13- -4 Bn sl rS
83.0 NOri/~ S. 0.3'
.8n s/
Z /VO /U r 1.0 BL S/ T-S ,tan
B to r. 8 ~n . j f= ' > h s ,
0. ' 13,7
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- 1 7-4 Alo v6 30
P_ Z z 4 NcA-,, 3 3 4/8 3 3 /0
P- 3 2-4 /V 0,V E 3 D 3 3 z %s Z 71,g /0
P-
P_ ab 7,E
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. -7(o r~o l~ t~JYJT?.~
SYSTEM ELEVATION
PKD,aosEo
, ~l NausE i ~ 1
~ + 6 M = M R P &0P f4V49 W r)
EL 6U. _ /oo ar~-•~-
91
52 - I S! (At1T~I1-~U~S
_o 6 -Sbl w c 1JL~ G`6R/~1N_ t`
_ N i QF= IT i "04TH
E
).1~111tti~. ~5tfL~S 'O - p1 ~a ` , P3 I LL' C_jSMgW S 11c,,V-T C
88 _6'
i
TC~ x C.ti e~ s
B7
;
I
;
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
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 SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
Y
2 Th u oln Fi f3? ,v. t 4,s
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR ANC) PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION TOWNSHIP/MUNICIPAL-ff Y: LOT NO.IKE NO.: SUBDIVISION NAME:
1/ 14 - J-1-1/11-4(.4 COUNTY: OVVT4E rS/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
QResidence IQ 4 New ❑Replace I -
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑S ❑u ❑ S ❑u ❑ S ❑U ❑ s ❑U ❑ S ❑U
[under Percolation Tests are NOT required DESIGN RATE: ( If any portion of the tested area is in the
s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-htdehFE3 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH4- ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
I
S IS j
B- DI\
B- v4 J) J3
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P-
P-
P-
P-
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
,
51 r2 b-4 j o~ a~Sf
I
l
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€ j
_
-
r 2.
S 1
- n N
' _
- 601 _ mm
_ _
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
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 SIGNATURE;
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 7't" 4
DILHR-SBD-6395 (R. 02/82) - OVER -
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