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Parcel 032-2013-50-000 01/31/2007 01:20 PM
PAGE 1 OF 1
Alt. Parcel 4.30.19.519E 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 5
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
O - CHUTE INC, ANNEXED 07/20/2000
ANNEXED 07/20/2000 CHUTE INC
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 6.370 Plat: 0025-ANNEXED 07/20/2000
SEC 4 T30N R1 9W PT NW NE LOT 2 CSM Block/Condo Bldg:
5/1244 ALSO A PARCEL DESC 1238/074 NKA
181-4084-15 (492) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
04-30N-19W NW NE
Notes: Parcel History:
Date Doc # Vol/Page Type
09/20/2000 630215 1544/151 WD
07/20/2000 626748 1528/142 ANNEX
05/09/1997 1238/074 WD
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2000
Description Class Acres Land Improve Total State Reason
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 0 0 0
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
Parcel 032-2013-40-000 01/31/2007 01:19 PM
PAGE 1 OF 1
Alt. Parcel 4.30.19.519D 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 5
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - CHUTE INC
CHUTEINC
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 13.870 Plat: 0065-AX-1282/614 #569943 '97
SEC 4 T31 N R1 9W PT OF NW NE 13.86A LOT 1 Block/Condo Bldg:
CSM 5/1244 ANNEXED TO VIL SOMERSET'97
NKA 181-4060-30 (444) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
04-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/16/1997 599943 1282/614 AX
07/23/1997 1237/572 WD
07/23/1997 657/402
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 02/04/1998
Description Class Acres Land Improve Total State Reason
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 0 0 0
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
A- I
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR \ f 'I FETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS U I ` DIVISION
P.O. BOX 7969 REAU OF PLUMBING
MADISON, WI 53707
(CONVENTIONAL DALTERNATIVE state Plml.D. Number
t III assigned
El Holding Tank ❑ In Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.
Name of Plumber: /MPRSW No.: Count Sanitary Permit Number:
SEPTIC TANK/HOLDING TAN :
MANUFACTURER: / LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
A ! PROVIDED: PROVIDED
G C I s.' ~.J OYES ONO OYES FIND
BEDDING: VENT DIA.. VENT MATL: HIGH WAT R NUMBER OF
ROAD. TPF'PERTY ELLBUILDINGVENT TO FRESH
z AIR INLFjr1
FEET E:
/
OYES NO f. DY S FIN NEAREST /
DOSING CH MBER:
MANUFACTURER. BEDDING'. LIQUID CAPACI V UMP M DEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ONO ,,,,r OYES ONO DYES ONO
GALLONS PER CYCLE: UMrrnNOC NT LS OPERATIONAL NUMBER OF PROPERTY WELL IBU,LDING VENT TO FRESH
(DIFFERENCE BETWEEN 1 FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES% ONO NEAREST ~
SOILABSORPTIONSYSTEM.Checkthesoil olst reat thedepth.of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF DISTR. PIPE SPAJ~C/~~~~y1.l,JJJJJVVVVVG COVER JINSIDE DIA SPIT ILIOUID
DIMENSIONS TRENCHES ~ L/ ~ / MATERIAL' PIT DEPTH
GRAVEL DEPTH FILL DEPTH OISTLIPIPF DISTR. PIPE ISTR. PIP A RIAL: NO. DISTR. NUMBER OF PROPERTY F1 BUILDING: V NT TO FRESH
BELOW PIPE~f ABOVE COVER ELLEV. INLET ELEV. END PIPES FEET FROM LINE l AIR INLET.
sfu 1J.7o p1 ~i ,-I l NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture fr he fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems t 'm ke certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria r edium sand. TIONS MEASURED.
YES ONO
SOIL COVER [TeXTURE ERMANENT M RKERS OBSERVATION WELLS
DY S ONO DYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH,BED =014L L SOU D/ SEEDED MULCHED
CENTER EDGES /
YES ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH WO. -OF LATERAL SPACING QRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIP DISTHIBUT ION PIPE MATERIAL & MARKING
ELEVATION AND ELEV. ELEV.. DIA ELEV. PIPES DA.
DISTRIBUTION
INFORMATION HOLE SG ID14 I LLE D CORRE C I L Y ICOVFR MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
OYES NO % DYES ONO
COMMENTS: MARKERS: OBSER ATION WELLS: NUMBER OF PROPERTY WELL: BUILDING'.
FEET FROM LINE
L_]NO OYES ONO NEAREST
41 1,;L
5 S 2
53,1 ,7
J S'4)'
Z
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATUR TITLE DILHR SBD 6710 (R. 01/82) "
DEPARTMENT &F APPLICATION
SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Mailing Address:
Property Location: -QIs4 yyu3ga Township: County:
~W t/a~pN/C t/aS ~T3V NCR E (or) W o
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
LdW { 3S- (If assigned) t2
TYPE OF BUILDING
Number of
KPublic* ❑ Variance* ❑ Other (specify)* Bedrooms:
❑ 1 or 2 Family *State Approval Required. e -S
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: G
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA ~r ~t
(Minutes per inch): PROPOSED (Square feet): ~rst`New ❑ Replacement ❑ Experimental lal Seepage Bed ❑ Seepage Pit
G/ j ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: f Owner's Name as isted on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Sign e: MP/MPRSW No.: Phone Number:
s g /V 5' („s).;~ye' sy
Plumbe 's Address. Nam of D signer-
COUNTY/DEPARTMENT USE ONLY
Signatur of sluing l1g t: Fee: Date: ~gppRO'ED Sanitary Permit Number:
- k 6 ~ T ) r F t` ❑ DISAPPROVED
e~_ Reason f r spproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
8K 808 Rediform
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rL'AN PPROVAL ^ DIVISION OF SAFETY & BUILDINGS
APPLI TION PRIVATE SEWAGE SYSTEMS 201 E. BUREAU OF Washington Avenue, Rm 178
P.O. Box 7969
Madison, WI 53707
INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are receivers
The back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration,
Document Sales, 202 South Thornton Ave., Madison, Wisconsin 53703, Telephone (608) 266-3358.
1. PROJECT INFORMATION (Type or print clearly)
ect of Submitting Party (Plans returned to same) Name
Proj67
/i
Street & 2No. Project Location Street & No. or Legal Description
City State Zip Code City County
i Village of
Ale, w 9/,- -Menei / - Town
e- s
Designer Telephone No. (Include Area Code)
2. THIS APPLICATION IS FOR A:
❑ New Mound System (3) LJ Holding Tank (2)
❑ New Pressurized System on site not suitable ❑ Petition For Modification (6)
for conventional (3) ❑ Replaoement Mound (4)
Replacement Pressurized System on site not ❑ System in Fill (1 )
suitable for conventional (4) ❑ System in Flood Fringe (1)
❑ Pressurized System on site suitable for ❑ Groundwater Monitoring (7)
conventional (1)
Conventional System Public Building (1)
3. FEE COMPUTATIONS (Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE
3a. 150 1,500 gallon septic tank - 25.92 4a. E~' dp
1,501 2,500 gallon septic tank 32.40 4b.
3c. 2,501 4,000 gallon septic tank - 45.36 4c.
3d. 4,001 8,000 gallon septic tank - 58.32 4d.
3e. 8,001 - 12,000 gallon septic tank - 71.28 4e.
3f. Over 12,000 gallon septic tank - 84.24 4f.
39. 500 - 1,000 gallon pump chamber - 25.92 4g.
3h. 1,001 2,000 gallon pump chamber - 32.40 4h.
3i. 2,001 4,000 gallon pump chamber 45.36 4i.
3j. 4,001 8,000 gallon pump chamber 58.32 4j.
3k. 8,001 12,000 gallon pump chamber - 71.28 4k.
31. Over 12,000 gallon pump chamber - 84.24 41.
3m. 500 - 5,000 gallon holding tank - 25.92 4m.
3n. 5,001 - 10,000 gallon holding tank - 32.40 4n.
3o. Over 10,000 gallon holding tank - 38.88 4o.
3p. Groundwater Monitoring - 27,00 4p
3q. Petition for Modification 27.00 4q,
Subtotal ~i ev
31. Walk-through plan review- 41.
Submittal of plans in polsoll,
by appointnt(Ml, with double lee
Total Fee Q J
COMMENTS:
0I I lilt st,l, 1)748 IN. ea!ti2)
uvftf
P1 b•. # 60
PROJECT DETAIL DATA SHEET
NAME OF BUSINESS >C r Uzcf Z'
LEGAL DESCRIPTION 2 W_
OWNER MAILING ADDRESS
J ZIP/
ARCHITECT, ENGINEER, -SADDRESS I!'
zt/
PLUMBER OR DESIGNER
S ZIP 3"1z"
TELEPHONE NUMBER %G 3 %1_2
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed. Please consult Section H 62.20.
Existing building New building tl Addition
( ) Apartments and condominiums . . . . Number of bedrooms
( ) Assembly hall . . . . . . . . . . . Seating capacity
( ) Bar . . . . . . . . . . . . . . . . Seating capacity # of meals served
( ) Bowling alley . . . . . . . . . . . Number of lanes ( ) With bar
( ) Campground and camping resorts . . . Number of sewered sites
Number of unsewered sites
Total number of sites
( ) Camps . . . . . . . . . . . . ( ) Day use only Number of persons
( ) Day and night Number of persons
( ) Catchbasin . . . . . . . . . . . . . Number
( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons
( ) With kitchen Number of persons
( ) Dance hall . . . . . . . . . . . . . Number of persons
( ) Dining hall . . . . . . . . . . . Number of meals served daily _
( ) Doq kennels .
. Number of enclosures
( ) Drive-in restaurant . . . . . . . . Inside seating capacity _
Car-service Number of car spaces
Dump station . . . . . . . . . . . . Number of dwnp stations _
( ) Employees ( total of all shifts) Number of employees
( ) Hotel ( ) Motel ( ) Cottages Number of units with 2 persons per unit
Number of units with 4 persons per unit _
( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff
Number of office personnel _
Number of patients _
MO hlle home parks Number of sites
Nursing homes . . . . . Number of beds _
( ) Parks . . . . . . . . . . Number of persons_ ( ) Toilets ) Showers
( ) Restaurant . . . . . . Seating capacity
( ) Dishwasher and/or dispu,al( ) 24-Hour service
ror(l Total number of CLAstul,ier,.
Number of classroaIr i Mra~,hnwer~:
c 1cj:jr Total n!iniber of n.
i
}
-2;. vIndicate whether the following facilities are present.
Floor drain yes L'__ no Number of drains
Food waste grinder yes no j.--
Dishwasher yes _ no L-
Automatic clothes washer yes _ no Number of clothes washers
3. Septic tank capacity
Holding tank capacity _
Septic or holding tank manufacturer
4. SEEPAGE TRENCHES: total square feet width of trenches
length of trenches depth
number of trenches
SEEPAGE BEDS: total square feet width
length of bed depth
SEEPAGE PITS: total square feet outside diameter
depth below inlet _
total depth from top to bottom of pit
Signature of person completing form: FOR DEPARTMENTAL USE ONLY
Address
zip
Telephone Number
Date ._it
l
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So rYl L~ ~"S~r Ta cv yS~~/~
e~
Gov
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30
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41 " 3~'3
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Department of Industry, Labor & Human Relations
Division of Safety & Bldgs.
State of Wisconsin Bureau of Plumbing Platting & Fire Protection
P.O. Box7969
Madison WI. 53707
Tel. 608-266-3815
~a
IN ALL CORRESPONDENCE
f REFER TO PLAN
IDENTIFICATION NO.
NAME OF PROJECT 8
TYPE OF APPROVAL G`
STREET AND NO. ~14[V
Y ^ jg
CITY OR TOWN TY STATE ZIP OfI,C
F
OWNER .i-1-., k-~,
Gentlemen:
Examination of plumbing plans and specifications for the above-mentioned project has been completed. In accord with Chapter 145,
Wisconsin Statutes and Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon com-
pliance with the stipulations indicated on the plans. Please review your code for the requirements of each code section noted.
The architect, professional engineer, registered designer, owner or plumbing contractor shall keep at the construction site one set of
plans bearing the stamp of approval of the department.
In the event installation of the plumbing improvements or system has not commenced within two years from this date, this approval
shall become void and new application shall be made for approval of these plans before work may commence.
In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, pla
omissions, examination and reserves the right to order changes or additions should conditions arise making this necessary.
This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit require-
ments of the city, village, township or county in which this installation is to be constructed. Failure to obtain local permits will auto-
matically void this acceptance.
Sincerely,
CUlifl~~
James Sargent-Bureau Director
DATE:
PLANS REVIEWED BY: I - J
cc: DPS-OWS Owner DI LHR
Local PI Plumber H & R (2)
County Mfg. Rep. Bur. of Health Fac. & Services
Rec. & Env. Services
DILHR SBD-6099 (N. 06/80)
SBD 6678 (9/81) (Plb 100a)
Detach And Return STATE OF WISCONSIN DILHR
Upper DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
Any Return Correspondence P.O. BOX 7969
MADISON, WI 53707
608-266-3815
DATE: PROJECT:
,'4, 30,19W
J ,
JAIN!
Rr)x
PLAN ID. #
DETACH HERE
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ Fee Received is $
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent. ❑ Condominium declaration. (1 copy)
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2)(a) Wisconsin
Administrative Code. ❑ Affidavit enclosed. IV. Holding Tanks
❑ Profile of holding tank showing vent, manhole alarm and
manufacturer if precast. Complete construction details if
11. Pressurize Distribution Systems (Mound or In Ground Pressure) site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy) government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation from county (1 copy).
test data. ❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to any building, wells, water service piping, water
❑ Plan view of system. ❑ Plot plan.
course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
III. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp- ❑ Calculations for total lift pump discharge, head and gallons
tion system extending 25' on all sides.
~ pumped per cycle.
❑ Elevation of permanent reference point (benchmark). ❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide
soil data. ❑ Detail & model of pump or automatic siphons including
size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water
siphon(s).
course, swimming pools, water service piping, Etc.
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester (1 Copy). ❑ Copy of onsite report by county or district staff.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON W 7969
HUMAN RELATIONS
LOCATION: SECTION: TOWNSHIP/Iyft7fdf`tPAtiTY: LOT NO.:BLK. 0.: SUBDIVISION NAME:
41 /T3vN/Rf~ (or)WI 5~4 e- 10
lWt ~/A4
2 e~ l~~
COUNTY &WMER'S BUYER'S NAME. MAILING ADDRESS:
e- Wi'5
USE DATES OBSERVATIONS MADE l -
NO. BEDRMS.:
~ ❑Residence COMMERCIAL DESCRIPTION:
New ❑Replace P_ OFILE DESCRIPTIONS: 1PERUCTLATION TESTS: I A/A IAI)Jer , 7-7-5.2-
t
RATING: S= Site suitable for system U= Site unsuitable for system "j is / 1
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK:'MCOMMENDEDSYSTEM:(optional)
;KS ❑U IKS ❑U S EU ES U ES
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL V
~ ~ If any portion of the lot is in the
under s. H63.09(5) (b), indicate: f 7~ 1 7 Floodplain, indicate Floodplain elevation: IVA
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 3 7 S' 7
Sr'
B-5 77 1 7 6.
B e7 .7 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 3 7 /?ke 31-
;2- ell,
P . t
P-
P-
LP--
PLAN VIEW: 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 slop.
SYSTEM ELEVATION 7'T
E
i
te- He h- D 7- _'T
,a
N
40
y y
opt
3
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative 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:
/ f U f (J
ADDRESS: i CERTIFICATION NUMBER: PHONE NUMBER (optional):
--------~1.___.___.~.__L ------1--- ~-7CST SIATU E_:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
DILHR-SBD-6395 (N. 03/81) _