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Parcel 032-2095-10-000 05/20/2005 08:57 AM
PAGE 1 OF 1
Alt. Parcel 23.31.19.925 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
HENDRICKSON, SHARI M
SHARI M HENDRICKSON
626 200TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 626 200TH AVE
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 8.200 Plat: 2442-SERENITY
SEC 23 T31 N R1 9W PT SW SW LOT 1 PLAT OF Block/Condo Bldg: LOT 1
SERENITY ALSO PT OF LOT 2 DESC AS COM NE
COR LOT 1; TH N 89 DEG W 414.52';TH N 00 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
DEG E 423.59 FT; TH S 88 DEG E 23-31 N-1 9W
412.28';TH S 00 DEG E 420.82' POB
Notes: Parcel History:
Date Doc # Vol/Page Type
10/23/2001 659904 1744/117 QC
07/07/1998 582429 1337/583 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 8.200 74,100 148,300 222,400 NO
Totals for 2005:
General Property 8.200 74,100 148,300 222,400
Woodland 0.000 0 0
Totals for 2004:
General Property 8.200 74,100 148,300 222,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 110
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 032-2095-10-000 05/12/2005 08:57 AM
PAGE 1 OF 1
Alt. Parcel 23.31.19.925 032 - TOWN OF SOMERSET
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
HENDRICKSON, SHARI M
SHARI M HENDRICKSON
626 200TH AVE
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 626 200TH AVE C/"{
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 8.200 Plat: 2442-SERENITY
SEC 23 T31 N RI 9W PT SW SW LOT AT OF Block/Condo Bldg: LOT 1
SERENITY ALS PT
COR LOT 1; 9 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
D TH 23-31N-19W
412.28';TH S 00 DEG E 420.82' POB
Notes: Parcel History:
Date Doc # Vol/Page Type
10/23/2001 659904 1744/117 QC
C SM q/1 0--7- U 07/07/1998 582429 1337/583 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 8.200 74,100 148,300 222,400 NO
Totals for 2005:
General Property 8.200 74,100 148,300 222,400
Woodland 0.000 0 0
Totals for 2004:
General Property 8.200 74,100 148,300 222,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 110
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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DEPA-ITMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
.P.O. BOX~1969 BUREAU OF PLUMBING
PvIADISON, WI 53707
.
C CONVENTIONAL ❑ALTERNATIVE slate Plan ID.Number
(lf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. t7 INSPECTION DATE
BENCH MARK IPerm-n, reference poem) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.. CST REF PT. ELEV.
r
Name W Plumber jMPWPRSV1 No! ' IC1,1111Y. Sanitary Permit Number
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY . ]TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COV EH
PROVIDED. PROVIDED
❑ .
YES ❑NO ❑YES ❑NO
BEDDING VENT DIA. VENT MATL HIGH WATER NUMBER OF TROADPROPERTY WELL. BUILDING VENT TO FRESH
ALARM FEET FR O LINE. AIR INLET
❑YES ❑NO ❑YES ❑NO__NEARESr---
DOSING CHAMBER:
MANUF ACTURFR JBEDDING [1111111 CAPACITY PUMP MODEL PU MP: SIPHON MANUF AC HIRER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PuMP AND CONTROLS OPERATIONAL NUMBER OF PNOPFRTY WELL BUILDING IVENTTOFRISH
(DIFFERENCE BETWEEN FEET FROM AIR INLET
PUMP ON AND OFF) ❑YES I_ NO ~N-EAREST--
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing A^,+~ TF H MATLHIAI A"' NANKIN(,
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
F INSIDE DIA J =PITS LIQUID
CONVENTIONAL SYSTEM: NIOIH LENGTH NO OF rR PIPL S"', INr, COVSI~
BED/TRENCH THFNCHES iATEEI IPIT DEPTH
DIMENSIONS
(,l; 1 DI i''I LL DEPTH J~)[ ti[li PIPE DISTR ERIAL OF ROPERTY WELL BUILING VNT TO FR ESH
.
BE L ri1 ,13c)VF COVEN E V INI f f ELEV. ENO PIPES LI NE. FEET FROM AIR INLET
N E,0. R EST
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-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO _
SOIL COVER iEY.T UNF PERMANENT MAHKF HS F0[3SEHV ATION WF LLs
❑YES ❑NO YES ❑NO
DEPT 11 OVER THE N( 11 Bf I) DEPTH OVEN THE NCH BF fJ DCPTH OF TOPSOIL SOf10FD SEFDEO MULCHED
EN I EH FD(,ES ~I
1YES ❑NO ❑YES LJNO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: _
:"iI IJ TH LEN(,TN NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
'AA NIFOLD PUMP M ANIrOL(J DISTR_ PIPE MANIFOLD MATERIAL NO DISTH. DISTR. PIPE OISTHIBUTION PIPE MATERIAL & MARKING
EI EV.. ELEV. DIA ELEV.' PIPES CIA
ELEVATION AND
DISTRIBUTION
SIZE HOLE $PA(.ING ORILtE O(,OHRE(: T lY COV ER MEHIAL VEHTICAI LIFT CORRESPONDS iO APPHOV EO
JHI,
LE
INFORMATION PLAnIs
❑YES ❑NO ❑YES ❑NO
PERMANENT~.AARKEHS JOBSERVATION WELLS TNE BER OF PROPERTY WE=G
COMMENTS: .
T FROM
❑ YES ❑ NO ❑YES _ ❑ NO _ REST-
S System on Retain in county file for audit.
Reverse Side.
SIGNATURE _ TITLE
DILHR SBD 6710 (R. 01/82)
LA
r-~
r• e x+
Jrt, -15
W
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aG
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1
'Al
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PI-B 67 State and County State Permit #
u Permit Application County Permit #
--Y 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:
2 a
104- .2 0 B. LOCATION: 54V iv Section ,2a, T_3LN, R
I [I (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY:., *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks e--s...je_
HOLDING TANK CAPACITY Total gallons No, of tanks
Prefab concrete Poured-in-Place Steel 7--7--Fiberglass Other (specify)
New Installation e.- Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area ~sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
5,2 Seepage Bed: c~ Length Width4_Depth :-Tile depth (top) , . i~ No. of Lines '!a
Seepage Pit: Inside e6ameter Liquid Depth No. of Seepage Pits
Percent slope of land- Distance from critical slope
WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner: r
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 Certified Soil Tester,
NAME C.S.T. #
and other information
obtained from M, C. y. .4, owner
Plumber's Signature
's Address P MPRSW#Phone #,~TY
Plumber
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
)
E
,
E
E ,
E
i ;
3
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY -
Date of Application, Fees Paid: State County Date
Permit Issued/Rejected- (date) Issuing Agent Name`
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 7/1/78
e LH, lib Rev. 9/78
- - REPORT ON SOIL BORINGS AND PERCOLATION TESTS
y WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
y LOCATION: ~ f---"1Y/., Section A T. .L.N,R-UA (or) Township r MuchApWity "•'1 r 5
Lot No. , Block No. - • County 11'r
Subdivision
wner's Bic Name: I 1 Q
Mailing Address:2a 1 Ci / -14 Ec d ✓V1 . s r~ cs 7~' Vt_/ 1. 5 y O Z j
TYPE OF OCCUPANCResidence No. of Bedrooms ; COMMERCIAL
4 EFFLUENT DISPOSAL SYSTEM: NEW 'r REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS r SOIL MAP SHEET NAME OF SOIL MAP UNIT
PERCOLATION TESTS IG t ✓J tc I ~q i✓1 SG~'1
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
DEPTH CHARACTER OF SOIL RAT,
NLAVI- SINCE HOLE HOLE AFTER INTERVAL
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/11
P- 7- U AA ,Is. Alo AU
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH ;DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- / r r r r
B- r re . ~i L h n r. G.
B- Ll B- L " w r. l
1 ~
B- r rr { n c
B- h it
1 ~.a ~I~ r r v ' -rf
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable arei,
Indicate number of square feet of absorption area needed for building type and occupancy 1 ~ L Indicate scale or distanCL
Give horizontal and vertical reference points. Indicate slope. 3 , J
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1, the undersigend, 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.
z Name (print) L'i L~`° ✓1 c o' Certification No.
" '::Address ' c] k , u ( o L, Ja'' l ja --,q,) i
Name of installer if known
Copy C - Property Owner CST Signature
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ST CROIX COUNTY CERTIFIED SURVEY MAP LOCATED
IN PART OF THE SW 1/4 - SW I/4 OF SECTION 23, T 31 N., R 19 W., TOWN OF
SOMERSET, ST CROIX COUNTY, WISCONSIN
i
~JN a~rr~Q 44NQ$ _OWNEP _9r
NORTH LINE OF THE 0
58' 14" W,
SW11'4-SW114, SECT/OW 23
19 00 SEE DICTA/L
19. 1
DICTA/L 00, N. 88058'14"W. z
O
0
N
N
NOTE THE TRUE FORTY
CORNER LIES S.88058'14"E.,
7. /5 ' FRAM THE NE CORNER
OF LOT
z
N 0
O _ O
I 0 N
0
SCALE ONE INCH EQUALS ONE-HUNDRED-FIFTY FEET In N w N In
100' 50' 0 100' 200' 300' 400' n
Z~QT /
N
LEGEND AREA two I
I~ TOTAL 439,083 SO. FT. CD In
r7 I" X 24° IRON PIPE SET WEIGHING 1:68 LBS. /0.080 ACRES -
PER LIN. FT.
EXC. R/W : 429,6/0 SO. FT. iy
• 1" (OUTSIDE DIAMETER) IRON PIPE FOUND ~y 9.862 ACRES /
J ~
~ ----M- EXISTING BARBED-WIRE FENCE ro i W +N
THE SOUTH LINE OF THE SW 1/4 OF SECTION rv I
23 - 31 - 19 IS ASSUMED TO BEAR S.88054-39"E. ~O 0
rrrrea!too
syy~~ C; Q f ~5.~''~,ri~ t ) f t
EN C_
CNYHAGEN 1o
07 .
ON, i
iS. v
♦MyJr JVI+ a O
SOUTH LINE OF THE SW//4 O'h -
OF SEC 7'101V 23 -3/-/9 ~0 S 1/4 CORNE
I COUNT
,VQJ✓ R!1? L;t' S_Sr 13+-16NF. - 334.19' .1 :
SW CORNER 27'44'
COUNTY MONUMENT S. 880 54' 39' E. 1003.12' S. 880 54' 39' E. 334.37'
^ ^ 66' TOWN ROAD
SIGNED G. DATED 'C 8
ALLEN C. NYHA N R.L.S. I d'Y VOLUME PAGE I D 7D
L ~'+,t srx,ag,akr~ ~s ~ F 4:ywieww
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AS BUILT SANITARY SYSTEM REPORT
OWNER ~T~v~ ~44i L'004-4SHIP SEC j N-R W
ADDRESS/ ST. CROIX COUNTY, WISCONSIN.
h
SUBDIVISION LOT i LOT SIZE
- PLAN VIEW I
Distances and dimensions to meet requirements of 1163 ~7
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
I
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191,
Indic at N r h rr w
BENCHMARK: (Permanent reference Point) Describe: '4/"
Elevation of vertical reference point: ~L~,Q/ -Slope at site:
Liquid Capacity: 4.y
SEPTIC 'TANK: Manufacturer: L
Number of rings on cover Tank manhole cover elevation:
'l'ank Inlet Elevation: Tank Outlet Elevation PUMP CHAMBER
Manufacturer: Number of gallons
Number of gal. pump set for a cycle- -gallons; Total capacity of
distribution lines gallon: size of pump head;
gallon per minute horsepower ;brand name of pump
and model number
Type of warning device _
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
`T'ype of warning device
SEEPAGE PIT SIZE; _ -Number of pits _ feet diameter
feet liquid depth- _ seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet. /
SEEPAGE BED SIZE: number of lines` width length /0 tile depth
th
- ~ g t
SEEPAGE TRENCH: width e n
PERCOLATION RATE--- AREA REQUIRED AREA AS BUILT-
INSPECTOR
/ -
DA'TEll ! j - LICENSE ONUMBOB
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. 60X'7969 BUREAU OF PLUMBING
MADISON, WI 53707
CICONVENTIONAL El ALTERNATIVE 7 State tuber.
(If assigned)
• ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
.
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER'. INSPECTION ~DATE
Steve Parent RR~~1, Somerset, WI ~IIIJ~`d 3 - `°j~
REF. PT. ELEV.: CST REF. PT. ELEV.
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN
SW SW, Sec. 23, T31N-R19W, Town of Somerset(N.Part)
N.m, of Plumber. MP/MPRSW No.. County Sanitary Permit Number.
Calvin Powers 1563 St. Croix 38494
SEPTIC TANK/HOLDING TANK: _
ROVIDED OVER
MANUFACTURER. LIQUID CAPACITY. TANK INLET FILE V.. TANK OUTLET ELEV.: PROVIID DLABEL LOCKING
O
f3. y~ ❑YES LINO ❑YES LINO
o') x'1.3
PR OPERTV WEL BUILDING VENT TO FRESH
ER NUMBER OF ROAD. LINE lAI LFJ
BEDDING. VENT A.'. VENT M TL. HIGH AT /
ALA FEET FROM
❑YES NO E NO NEAREST J
r
DOSING C A ER:
PUM /SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
MANUFACTU ER BEDDING. LIQUID CAPACITY PUMPM E. PROVIDED: PROVIDED'
❑YES LINO - ❑YES LINO ❑YES LINO
GALLONS PER CYCLE: PUMPANDCO OL PERA NUMBER OF PROPERTY WELL BUILDING (VENT TO FRESH
LINE AIR INLET.
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) ❑ ES LINO NEAREST
LFN(;TH DIAMETER MATERIAL AND MARKING
SOIL ABSORPTION SYSTEM. Check the soil moisture at the epth o I in9 F CE
or excavation. (If soil can be rolled into a wire, constructio shall cease until M IN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM: LIQUID
WIDTH LENGTH NO OF DISTR PIPE SPACING ryOVER AL INSIDE DIA ttPITS DEPTH
TRENCHES ` PIT
BED/TRENCH :
DIMENSIONS 2
GRAVEL DEPTI FILL DEPTH DISTH. PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO. DI NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESI
LINE ~O 1 r~ AIR_WLE
)W P fES ABO c88~Ej ELEV INLET ELEV END PIPES FEET FROM I
BE I_(
l~, 1 NEAREST -
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill m teri I for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound s stems to make cer in t t it ON REVERSE SIDE. SHOW ELEVA-
meets th riteria for medium and. TIONS MEASURED.
❑YES LINO
SOIL COVER TEXTURE PERMANE T MARKERS. 71 OBSERVATION WELLS
❑ ES LINO ❑YES LINO
SEEDED MULCHED
JDEPTH OVER TRENCH BED DEPTH OVER TRENCI DEPTH FTOPSOIL SOD D
CENTER EDGES.
❑YES' NO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER
WIDTH. LENGTH. NO.OF LATERALS ACING: GR EL DEPTH BELOW IPF.
BED/TRENCH TRENCHE .
DIMENSIONS
MANIFOLD PUMP MANIF D DISTR. PIPE MAN OLD MATERIAL: NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA.. ELEV. • PI S DIA.:
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRI ED CORRECTLY COVER MATE IAL PLANS
❑YES LINO ❑YES LINO
PERMANENT MAR RS: OBSERVATION WELLS: NUMBER OF L PR I NOPEERTY WELL: BUILDING.
COMMENTS: FEET FROM
❑YES LINO ❑YES LINO NEAREST
("3
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE
DILHR SBD6710 (R. 01/82)
DEPARTMENT OF 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'/z 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.
Prope y Q~vner: Mailing Address:
P' r Township: Count
L '/aS ,2 If iT ~ s N/R j (or) W
Lot Number: Blk No: Sub ivision me: Nearest Road, Lake o Landmark: State Plan I.D. Number:
(lf assigned)
d
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)*~~ Bedroom/
19 1 or 2 Family *State Approval Required.'
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY J(
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: S
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (SAuare feet): LO New ❑ Replacement ❑ Experimental Q Seepage Bed ❑ Seepage Pit
- ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name As Liste n it Test Re oYt (If other than present owner):
.
Private E:1 Joint El p Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Nam f Plufnber: ,,g nature: MP/MPRSW No.: Phone Number:
" snt 3
Plumb Address: / i Nam Designer: 71
`
! `S 9
!5F/ 7
COUNTY/DEPARTMENT USE ONLY
Signat re of Issuing Agent-
Fee: O Date : APPROVED Sanitaarry Permit Number:
~~r^'~~'~~ ~PJ(J ~Q O ❑ DISAPPROVED V2D 'K
Reason for Disapproval:
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)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, c DIVISION
LABOR AN P.O. BOX 76
.HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
% LOCATION: SECTION: TOWNS IP/MUNICIPAti-TY: LOT O.:BLK.NO.: SUBDIV SION NAME:
/T3:, , _C' - I ~ *4 /
COUNTY: OWNER'S/BUYER'S N F: / MAILI G ADDRESS:
4 z
7-
USE DATES OBSERVATIONS MADE
NO. BEp
Z Residence RMS.: COMMERCI L DESCRIPTION1~~Ne- PROFILE DESCRITIONS: PERCOLATIQN TESTS:
Residence /j' ~ ❑ Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: IMOUND: OUcIN-GROUND-PRESSURE: SYSTEM-IN-FILLHHilns[ziu NK: RECOMMENDE SYSTEP:(optional)
"S OU [i s Elul- [iJ E~ IF-is Elu)
If Percolation Tests are NOT required DESIGN RAT
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ~~l,",
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B
ti
Ja~
13-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD( PERIODZ PERIODS PERINCH
P- .3
P- - _3 J 3 <
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'/.
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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 nt): TESTS WERE COMPLETED ON:
- /Z
AD / CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DII_HR -SBD-6395 (R. 02/82) - OVER -
3t 3 .>ra= ~ °~~E .
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<aFt£ >r K.': i, uY ar=m. { i¢'€ t t011 n ms ob`h We CtP' ,ft ,4, :.aw ,>or,a(, and .ts£ rwi i.l.a
,,,v au ,,;l ,a`t3¢, y E,.i£` 7 'S as .,m. natl"~ dchansm, .iattl d.,.t: ,;3t,(L,E31w?s^ n ...a. £92'
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xa m, u , , ;.,,9 t"T in We W(, PO, to F € , plall'i I{;°. `h pi.v',~tr;
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4v.9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
' WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: Section:. 1 ,T._~(_N,R19..i (or)6-N ownship r MttabipQW
!
Lot No. Block No. r ~ r,..~., - County ~t'• ~--f G I X
u cd-krtsion Dame
wner s B yAK4 Name: \A] I I t ! t(AV" U / C C_j >_01
Mailing Address:. 20 V i cfi - 14 , ;'f'1 a rn f S a__ \A.Z r 5 '10 Z. ,
,:TYPE OF OCCUPANCY: Residence 1 No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM-OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS_Ll PERCOLATION TESTS !J'/ ~f
'SOIL MAP SHEET NAME OF SOIL MAP UNIT
PERCOLATION TESTS ~~~or~1 ~r~l vorvt~/°~'►
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RAT.
Num_ DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTE INTERVAL
BEER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MINA'
t ER _
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P_ 'Z1 Al
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P- -1, 7
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SOIL BORING TESTS
TEST TOTAL DEPTH , DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- I I S
B- L r 1 ,r a~ i~ " _
B-
-7 8 0 M.
1 V 1, " s
B_ -7
B-
-7 -2
B- 100o e- -7 1 :2 L
I , a PLAN 4VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate vrrthe Klan the locatyon and square feet of witabir• _
Indicate number of square feat of absorption area needed for building type and occupancy c.) I LA Indicate scale or dist.an,
Give horizontal and vertical reference points. Indicate slope.
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t`r 1, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods
} x8ro 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.
4
Name (print) l Certification No.
Address
Name of nstaller if known
CST Signature_[.~~~~ s
Copy C Property Owner »
~ ~ta~CU! /~l~f,PX, ~OO~fov~lar;,o~J ~FrsT~'P,<:G~/OlJ,O ~ f;0 ~ . ,Or
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