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HomeMy WebLinkAbout040-1192-60-000 t o O n O n y 0 d `r1 o c c m f c fD m CD ((D 5 v C Xk CD r. co M i (D 3 3 d o m o ao w w= N° i- o S 3 o O a) 3 (D N N go `.3 :a CD U7 F M N N q r2 ° tV i'S FD- Q 0 C7 7 O -0 0 :3 o CD CD 0 Gi O 7 N CL 7 N p_ O C !r (D CL A v> D a CD U) CL CD N W Q N IW 7 OD O j (D O O FD. N jz~ i O O 0 i~z O O M 1 0 r- (n (D (o N A A (CD I CD -4 < (n OJO Oo (D N •O* r_ m M .d* • O O O T O O O T l1~11 v - i A OIQ 3 to ai ai `n 3 u) u) -to v 3 3 v o v x v v v - I CD (D y 'D V7 p d a d ty m (D " o o o m N Dl N N N N 3 y N 3 m N N (D CD Q rt Z o ~ z ~ z z co Z D o O D v CL O :3 7 F), m m m (n (D CD m (D' v N N C CD M. C (D N 0) CD W (D (o d N CD Q N 7 _ CD CD Z O p Z N (D O Q) 0 n d A v 0 S Cn N oo~ W m00 CL o. ' ~ Z 3 3 3 3 c N p N Z CD ~ w w v C CD oo n CD m nD ~ (M U) a3 0 - m T O_ N (D T O 7 a 9 7 ' C (D g Z a co O a v x. v m m (S (D D x N N -gyp N A. CL ~(C) 0 0 cl CD voCD 3 I o N < (0(0 ) I b 1 (D t CD 3 m CD :3 - a ;7: Z o• n -o ~ m (D j 3 ~q O C O 7 Q (D N Ati o 0 b ti N N Oq W ffl O E» O yN O (D O ` w1 ti • AS BUILT SANITARY SYSTEM REPORT -NEIR 0, ADDRESS , TOWNSHIP 4 SEC TN R J C " W ST. CROIX COUNTY, WISCONSIN. BDIVISION LOT LOT SIZE PLAN VIEW Distances S dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4 r , h b -3TIC TANK(S), d~ . MFGR. CONCRETE 1;`. STEEL NO. of rings on cover Depth DRY WELL NCHES NO. of width length area no, of lines width length i area ~ depth to top of pipe :,;REGATE a RATE,;_ AREA REQUIRED AREA AS BUILT claimer: The inspection of this system by St. Croix County does not imply complete '.pliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for stem operation. However, if failure is noted the County will make every effort to termine cause of failure. ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. -'INSPECTOR DATED PLUMBER ON JOB Y 1 LICENSE NUMBER i ncn 0 cvn C7 ~ 0 a) l O fD 3 0 3 m (D a CD a t c a CD "m n 0 3 - # m o o CYl \J 3 a m (D m Z n N o E- M CD 1 0' 10" (D N N DJ N CK) n N -0 O n J J O O O 3 O 3 N Q o O C N N ~ II rj !r p (E CD (Dn a a J N co N e CD s Z) S C iii CD b r-T A CL c~ ((fl r cn -rt w N 00 00 < cn CD Z CD ° a Z < it "0 M M w.~" r Z 000 Z a00 , 'ar f i~1 ° v N ~ V Q ~tN 33 c y N cn 3. d _ o" a H A n r,~ (°p O 41 (O r- w (~D N y N) (D r ! " N IV 4. a CD N o f. Z 1 Z O o D j O Z 0 411 o n o" ? ~ • c) cn J tv U`f ~ Q (D C p QN, p -0 N. 0) CD N rn W (D N CL (D -1 Ch J J A Z O 77 0 CL • _I o (ij r° 9 C) r m N A 03 M (D M co CL z A 4a 0 :i fn N 4:z, rlzl ~y~' Q f Q i vi \ D A m W CD p p J C J 0 CD d J 0 N C CD 3 p d J M (D J T (7 J CL L c S (D Z D x _S p a n ~ y. (D X N N O -4 N O (D 4 ~.(a N p cn ~k O (D N 7 m ~ z ~3 o 77 ;w o o tv 0 :0 3 CD y o ti (D m a e ) 0 Parcel 040-1192-60-000 11/09/2005 12:24 PM PAGE 1 OF 1 Alt. Parcel 24.28.20.862 040 - TOWN OF TROY 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 - ZASKE, GEORGE V GEORGE V ZASKE C - IACARELLA ANN M IACARELLA ANN M 211 PLAINVIEW DR RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 211 PLAINVIEW DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 1.600 Plat: 0234-CROIXRIDGE SEC 24 T28N R20W PLAT OF CROIXRIDGE LOT Block/Condo Bldg: LOT 16 16 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 24-28N-20W Notes: Parcel History: Date Doc # Vol/Page Type 06/30/1999 605963 1428/334 WD 07/23/1997 1178/142 WD 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.600 78,800 278,300 357,100 NO Totals for 2005: General Property 1.600 78,800 278,300 357,100 Woodland 0.000 0 0 Totals for 2004: General Property 1.600 78,800 278,300 357,100 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 Form - S T C - 1 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP /ryc~ SEC. C/ T Z~'N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION ~~Jlx LOT 1t 2 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH.R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~Y ~i t."YaQ. ,l - ~-,i- z I j 1S1/alju5f.r7L~~ 6'a I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: dJZ; Proposed slope at site: 'SEPTIC TANK: Manufacturer: Liquid Capacity: v Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front Side Rear n feet From nearest property line Front, 0Side, 0Rear, 0 feet Number of feet from: well d(~ building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 1 PUMP CHAMBER 1 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: 1 Leng- th. Number of Lines: ~c Area Built: Y,~ i Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side Rear, O Ft Number of feet from well: ?~f 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: / Dated: Plumber on job: License Number : 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL E ALTERNATIVE State Plan I D Number. (If assigned) E Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI N ATE C.P~44o Ld WhitakeA R. R. 3, Rivets FaUls, W1 /UQtN~ BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF. PT. ELEV. SE SW, Section 24 , T2 8N-R20W, Town o4 Tt o y, Lat# 1 G, C Loixitidge Name of Plumber IMP/MPRSW N,.. County Sanitary Permit Number. Rogett Timm 3224 St. Cuix 58889 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL JLOCKING COVER PROVIDED. PROVI DED. 1 OYES ONO OYES ONO BEDDING. VENT DIA.. ~`NjRQ HIGH W JN BER OF ROAD: PROPERTY WELL BUILDING. VENT TO FRESH i~ ALARM FEET FROM LINE AIR INLET OYES ONO v ❑Y ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID C PACI TY P 1MP MO - PU MPSIPHON MANUFACTURER WARNING LABEL ILOCK PROV ING COVER IDED . PROVIDED: OYES LINO r" OYES ONO OYES ONO GALLONS PER CYCLE: MPAND ONT OLSOPE ATIONAL NUMBER PHOPERTY WELL JBUILDING I(DIFFERENCE BETWEEN FEET FRONE AIR"LET PUMP ON AND OFF) YES ONO NSOI L ABSORPTION SYSTEM. Check the soil m isture at the depth of plowing jLFN(,7If 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: WIDTH. 1 L ~ J ENGTH NO. OF DISTR. PIPE SPACING COVER INSIDE DIA -PITS LIQUID BED/TRENCH TRE1'~ _ MTRu~ PIT DEPTH DIMENSIONS C GRAVEL DFPTH FILL DEPTH JDISTR. PIPE DI$,j DISTR. PIPE MATERIAL. NO. ISTR. NUMBER OF PROPE WE BUILDING: VENT TO FRESH BE LOW PIPES : AI X E ELEV INL T'-E `N Z PIPES FEET (LINE AID INLET d~ ~ ' yC ~l • NEAREST-s MOUND SYSTEM: c 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- OYES O meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS OYES ONO OYES ONO DEPTH OVER TRENCH:'BED 7DEE~ITH OVER TRENCH. BED DEPTH OF TOPSOIL PED. SEEDED MULCHED CENTER GES. S ONO OY ES ONO OYES NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING JGRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA.. ELEV.. PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. OYES NO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL: BUILDING. NUMBER OF LINE.. t y EYES ONO OYES ONO NEARESOM 'E i ~ n Sketch System on R n in county file for audit. Reverse Side. [IGNATURE s TITLE: ter" DILHR SBD 6710 (R. 01/82) I Wisconsin APPLICATION FOR SANITARY PERMIT DILHR jv- COUNTY ~ OEPRgTTT1EnT OF (PLB 67) - InC1USTR EnT R6HUTRnRELRTlClnS UNIFORM SANITARY PERMIT # -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 PROPERTY LOCATION CITY: 1/4,, ,_l/4, S , T _1) N, R E (or)~.W ; TOWN LOT NUMBER BLOCK NUMBER SUBDIVISION NAME 7rN7EARE`STROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER e r' 10 TYPE OF BUILDING OR USE SERVED ESJ 1 or 2 Family Number of Bedrooms. - Public (Specify): I THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair SJ 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 ❑ 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 Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEPJI COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: El Private ❑ Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MNo.: Phone Number: ( 1 Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Ad 51.9 Disapproved -yZ44t X" CDC ~ El Owner Given Initial 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: 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. APPL ICAT LON FOR SANITARY PERMIT S 'I' C - 100 Iris appli.cati_ou 1`orin i5 to be comi>lercd in lull and 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 forin should be retained and completed when the property is sold and submitted to this office. with the appropriate dead recording. Owu(,r of Property Location of Property G i4 1_ `4, Section `L' S N- R J,- W Township 71 %i i 1 ing Address - ti Subdivision Name 6,r ~x 1_()t Number A~ Nrk-vious owner of Property It-A' 't'otal. Size of Parcel ls7g ~Lc5 Date Parcel was Created Are all corners and lot lines identifiable? Yes No is this property b(.,-ing developed for resale (spec house) Yes, No volume -l_ and Page Number -s recorded with the Register ,t Deeds - INCLUDE WITH THIS APPLI:CATtON ONE OF THE FOLLOWING. 1. Warranty Deed Land t:'nntract 3. other recording:: Filed WiLli rile Ruglster :)i of Lice In addition, a certified survey, -if available, would be helpful so as Lo avo.i.d delays ,t the reviewing process. If the deed description references to a Certified Survey Map, the the Certified 4urv,_~y Map ;hai_1 :also be requ_t_r.~d_ PROPERTY OWNER CERTIFICATION I (We) ceA_ti-6y -Mut aff sMtement6 on thi6 6ohrn cute t/tue. to the best o~j my (uWt f.riuwkedge; that 1 (we) am (aAe) the •witm (s) u6 the p,`topeA,ty delsc,,abed ,%ri tlc<~5 t-vi~uAuriatiuyt 6unm, by vi.A:tue u6 a wawuzrity de.e.d aecunded gin- the. 066ice up tht County Regi5teA o~j ve.ed,5 as Ducwnent No. - 1„~~ ; and that I (we) p~ie.~e-ratty own the p~topohed site Am -#he sewage. 015 a~ ~y~,tem (vn I (we) have obta4.ned an s a.5ernen,t, -(o Aun Witil .the. above de eAt'bed pA.opeAty, Gott the cunt .t~tuctt on O ~ s a.d 4 y.5 tem, and .tli c. =5 ame It" been due y ne_e_o q.ded iki the O (A ("AT o~ the County Reg,'5-ten o6 Deeds, a.5 Doe.wrnenvt No. n SIGNAT 2 ( 0 NE SIGNATURE OF CO-OWNER (IF APPL1CAIii.E) DATE SIGNED ~ DATE' SIGNED H Y STC - 105 r r H SEPTIC TANK MAINTENANCE A(;R ?E'ML;NT H 0 St. Croix County d OWNER/BUYER z; ~o . ROUTE/BOX NUMBER Fire Number 3 C I 11' Y/ S `I' AT C 1 ---Z I P-_. PROPERTY LUCA'1'IUN: "4-, Section__ r,N, RW, Town of ~<<f St. Croix County, Subdivision Lot number- 14, j i i lmpruper use and maintenance of your septic system could result in its premature'failure to handle wastes. Proper maintenance con- sists of pumping uuL the septic tank every Lhree years or sooner, it needed, by a licensed s_~tic tank uw1er. What you put into Lhe system can affect the function of the septic tank as a treat- menL stage in the waste, disposal system. St. Croix County residents ma be etib,:.le 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 submiL 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 un-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 to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- 10 ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zonin, Office within 30 days of the three year expiration date. S I G N E D St. Croix (ounty Zoning Office P.O. Box 90 Hammojid, W1 54015 715-716-2239 or 715-425-8363 Sign, date and return to above address. r f- (A n N I wEr' CA N N 3 0 C7 U) w ? M CD `G O Cl. cl) :E CD ~C9 a W,=G-~ 1 Q O c 0 C-0, 3 rc* ° 3 O s c. v w CD O A. 8 2wrn cDNw=( CL * CDaOo w w o m a~ _ CP =r = =r co r n 3 a O co .n► ~ W CD O_ w O W ? ? O O O O C_ c- j N O w a C `G O O:E OS 0wCD °~OaW~ - Cl) CD D n < CD CDCn Q, n Qo ~ CD (p a ~ _D c (D ..a ` g 1 w CD Cp O Q C w n 0- a Q• O M CD 0 Co C m 0 N CD _m Z D w Cep ~ 0 ~ ca0 Z m CD o CD g av, 3CD ww?a D =1 Cn v, D N C CD ° 0~ m CL r f acwfCDw C m CD 0 go ~ w CD C O a Cl) W (A N 0 G.4 -ate N~mQm (D _ (-a - c + c Co ~ y N co; a: U Q. wc cr :E 0. N0 Rt wow Ch cc - a ao (D Q:3 asv; 00~C ~cc~ oN~0oca a o a c w m -4 w Co N S. CD "`r a c a s c CD w Q p o' O ~3 . aw B w ate' o ~R 0 o I DEP;,RTRl _NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX ON, WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION = W-NSIP MUNICIPALITY: LOT NO.: BLK. NO.: SUBDI VISION NAME: s- )/4 v)/ z Tz gN/RzoE l COUNTY: NJNEFi:S)9Ul'ER'S NAME: MAILING ADDRESS: ST 1X( ~.L ! -t"'OPAO \/JH I-r 4 Kf'' I t-~1 f ~•~~r .l L:)k"~, >T USE DATES OBSERVATIONS MADE NO. BEDRfZ: COMMERCIAL DESCRIPTION PROFILE DESCRIPTIONS: PERCOLATION TESTS: l Lid,nc, A , I Resi ___1 y f I <-I New Replace _7¢ 47// RATING: S= Site suitable for system U= Site unsuitable for system ~CON'JENTIONF,L: MOUND: IN-GROUNaPRE.SSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ~i U ff~~ J CC U ❑ J cc u ©S ffL ~~J11 ~ ❑ S u ❑ U~^~~/G.rJT loN~l. ""~;~~N•5 X /70 li Percolation Tests are NOT re wiN RATE q red D ESI Gx I I( any portion of the tested area is in the j nder s : u.H63 .09(5) (b), in dic ate: 1\1 Floodplain, indicate Floodplain elevation: f{` 1 pE~fMA.L PROFILE DESCRIPTIONS F30RING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH fFi ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) p 0.7a' BL L~ 0' 5,,j S1 L I,;O' /3 Q r B- I ~,COt' °I/•~3 /Q C' E > 8,C"0 N\ED f> Z.00' Y 5'n') 0:~0't3LL; ~.ao' ~o ~N StL; o.~o ~oa~ L-S C5 w Cry;0,70' t3~/ M,F-0 5w~5Htt.S 3,J S; 7-C)' E3,j SL' at_ L) Z,90' iZD i~nl S i ~O, 70' GS w GrL; B 1 ~7zU `j O, !a5 N~aI~ >7,2C~ z o' pniMe:tD S ra,mJ' P~/ Lws Y6r/S - - - B- B- p`~`'J' ~L. PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCITES RATE MINU-1 ES ELEV. NUMBER -t1,Lf-- +ES AFTER SWELLING INTERVAL-MIN. PERIOD PERIOD 2 PERIOD 3 PER INCH P. 3,89 N Z - - > < 3 9! , 09 P- -/S- t~n"i;E 2 -3 35' P- -I ~-P---- - PLOT PLAN: Show locations of percolation tests, soil borings an the ensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their to tion on tho { plan. Show the surface elevation at all borings and the direction and percent of land slope. A-P P 2oX! Mk-TE: SYSTEM ELEVATION 8Z Z:0 '-nT L I/Q P-1 EKIST►5EPTI"~C.- TNT na K. / rQ I r / n~/ SAO I ~ ❑ 5 A C.k 4oF_` F' ! T ~ ltg J 7 n j o PE RCOL_A`r/ od TE S7- 3BF[jr-H "Mir- IS `I7eLLow sPOr JtT v p~NGH M~t~ SPOT fstN pgO~L' .pN J ~Lrpy~l CONLiLETE `f O!4 Gb/VG?-ET-E PiT- 5LAI-' p F ON r D cDo R_ L_e~' C_ A _r 10 Aj 'V S~r_~ TGH M 0 5 D 5 l T'E ~ v 3 S ° M I L E ALA I N y tw./ fu undersigned, hereby certify that the soil tests reported on this form were made by°ie i ccord 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 b t of my knowledge and belief. fv ANE (print) TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMB ER(option;30 I I z N Cs__ 1~ a O r✓~-f~l,~` f t 6 7/ 3 8G - 4.0 5 o CS SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILH1;-SP.D-6395 (R.02/8,2) - OVER - • ROHL & TIMM EXCAVATING JOB SHEET NO OF Z 310 Arch Street HUDSON, WIS. 54016 CALCULATED BY v DATE _ (715) 386-8664 CHECKED BY DATE_ SCALE /~yf 6C.~ OB /c"` a ~L.t ~ ~.y/{ t F1 ~ ~ I y A : t/c.~. / I . 5 t 1r1 7.r en u t 4,11 i 1 F -t7 f enIV, lit r r t PRODUCT 204-1 [NE~ 1 nc., Groton, M., 01471 . • JOB ROHL & TIMM EXCAVATING 310 Arch Street SHEET NO. OF HUDSON, WIS. 54016 CALCULATED BY DATE (715) 386-8664 CHECKED BY f DATE_ • SCALE V~N 7 4.- ► ney C C41 a t f r?2 P 4 L _ 1wl re C lCA 3 ~ ! I i PRODUCT 2041 EN-k~Bq Inc.. Groton, Mass. 01471. RE-PORT OI' ITISPI;C'110'_~--INDIVIDUAL SL11ACE DISPOSAL SYS'-E1i • Sanitary Permit--~ State Septic 1E ; T61,INSHIP . t: Croix, County SJ'.PTIC Tn'1T Size gallons. `,,uinber of- Compartments Distance 'From: dell ft. 12% or greater slope ft. Building 1 ft. Wetlands f ILighwater ft. DISPOSAL SYSTE:1 Tile Field or Seepage Pit(s) Distance From: taell ft. 12% or greater slope ft Suilcinj ~ ft. _ Wetlands f FIELD ;1igt~water ft. Total length of lines ft. Number of lines Length of each line ft. Distance between lines ft. Width of the trench ~ft. Total absorption area c)~ sq. ft. Dept', of rock below tile in. Dp-pth of rock over tile in. Cover avers©clc - Depth of the below grade - in. Slope of trench -in per 100 ft. Depth to Bedrock £t. Depth to ground water ft. PITS 'Dumber of pits Outside diameter £t. Depth below inlet ft. Gravel around pit: `yes no. Total absorption area sq. ft. c Square feet of seepage trench bottom area required square feet of seepage nit area required Inspected by.: T Title. i - Approved Date 197, . Rejected Date 197. EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH ► P.O. BOX 309 MADISON, WISCONSIN 53701 i. REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: Section, -rVN, 19_ &(or ownship or Municipality Lot No. , Block No. lO _ 6i ~ Count Sl`, zs~ j+t /L/ bdi ision Name y -'T Owner's Name: ( s e / j Mailing Address: 43 L c`,C e"0 204( =f/lr - e/ As.tl , TYPE OF OCCUPANCY: Residence X No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOILMAPSHEET_ OFF'~~~ SOIL TYPE 0&,4'•t" Ola-14klc PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL j NUM- INCHES THICKNESS IN INCHES MIN/IN 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 BER V0 -3 3 r /f xe, 1 rZ - C r-t //C) ; L , 21 I P y4 - : e Sr _ / rl _ _ ~l 3 X2 3 '.2 SOIL BORING TESTS EST C)?A DE?Tk' i •l PT F I, t r'~ T EP, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) IV A.c~ a 0 e,,O.-set` r~ LOP 'r & eg&t 'e-5, 56 ;ye PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square f et of suitable areas. Indicate nu b r of square feet of absorption area needed for building type and occupancy. z~, Soo y us~~~~~` ~i~ Indicate scale or distances. Give horizontal and vertical reference p i i slope.ST~=•-- ^f- Ots 'e ~ k - - E ~qQ t - 41 tN 101, - - - - - - 1 ~ l 1 t t € 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 location of test holes are correct to the best of my knowledge and belief. Name (print) . 4'Certification No. Address Z Name of installer if known CST ignat X 7 .1 C,161L COPY A - LOCAL AUTHORITY PLB67 State and County State Permit Permit Application County Per for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required _ State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: d 0- d ci - B. LOCATION: SSE L1~1'/4, Section T "N, RZQ (or) .Lot# Z6 City FAV Subdivision Name, nearest road, lake or landmark Blk# Village Township j.~je C. TYPE OF OCCUPANCY: 'Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms _ No. of Persons D. TYPE OF APPLIANCES: Dishwasher X YES NO Food Waste Grinder YES XNO # of Bathrooms Automatic Washer A YES NO Other (specify) F SEPTIC TANK CAPACITY Total gallons No. of tanks 'Holding tank capacity_ Total gallons No. of tanks !.ew Installation X -Addition- Replacement- Prefab Concrete- X ''Poured in Place -------Steel _ Other (specify) i;FFLUENT DISPOSAL SYSTEM: Percolation Rate 1) _2= 2) y 3) Total Absorb Area sq. ft. i,ewo&_ Addition _ Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length. _Width Depth " Tile Depth " No. of Lines Seepage Pit: Inside diameter Liqui Depth- _ Tile Size Percent slope of land 67- oct ~/,tr~ Distance from critical slope JKV I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Ce ified Soil T to l/ NAME /Zr_ C.S.T. # - - and other information obtained from lzoe_ ,c,• ilder .l Plumber's Signature _ NIP/MPRSW#3 Phone #'71f Plumber's Address 4KIZ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). F se- ~l~A~'tr ~id /bo V, 02 Y , Slop, ~ Do Not Write in Space .Below R DEPARTMENT USE ONLY ,tjC) Date of Application . Fees Paid: State/-01Q~Cou ty Da Permit Issued/ (date) Issuing Agent Nam Inspection YesNo Valid# Sate Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 state (pink copy) 4. plumber (canary copy) Revised Date 6/1 /76 b6 - - -