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07/19/2005 11:38 AM
Parcel 042-1045-95-000 PAGE 1 OF 1
Alt. Parcel 17.29.18.261A 042 - TOWN OF WARREN
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* MELLO, ROBERT L & LUCILLE
ROBERT L & LUCILLE MELLO
1046 100TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1046 100TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 2.400 Plat: N/A-NOT AVAILABLE
SEC 17 T29N R18W COM NW COR NE NW, TH E Block/Condo Bldg:
20 CHNS, TH SW TO PT 5.52 CHNS S OF POB
TH N TO POB EXC PT TO PARCEL DESC IN Tract(s): Sec-Twn-Rng 40 1/4 160 1/4)
995/603 17-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 995/603 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Last Changed: 10/22/2001
Valuations: _
Description Class Acres Land I prove Total State Reason
OTHER G7 2.400 39,500 ( 128,000 167,500 NO
Totals for 2005:
General Property 2.400 39,500 128,000 167,5000
Woodland 0.000 0
Totals for 2004:
General Property 2.400 39,500 128,000 167,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
Category Amount
User Special Code
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
Parcel 042-1021-50-000 07/19/2005 11:29 AM
PAGE 1 OF 1
Alt. Parcel 08.29.18.124 042 - TOWN OF WARREN
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
MELLO, ROBERT L & LUCILLE
ROBERT L & LUCILLE MELLO
121 LONG MEADOW LA
ROTONDA WEST FL 33947
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: - Acres: -14640 Plat: N/A-NOT AVAILABLE
SEC 8 T29N R18W SE SW EXC PT TO PARCEL 1 Block/Condo Bldg:
DESC IN 995/603 f/ Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
_ _ _ 08-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 ` 995/603 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 11.640 1,500 0 1,500 NO
OTHER G7 3.000 18,000 33,400 51,400 NO
Totals for 2005:
General Property 14.640 19,500 33,400 52,900
Woodland 0.000 0
Totals for 2004:
General Property 14.640 19,500 33,400 52,900
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges 00 Delinquent Charges
00
Total 0.00
A AS BUILT SANITARY SYSTEH REPORT
, s SEC . 1 R~W
OWNER ~YL~ TOWNSHIP C -~1 -
ADDRESS ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION LOT - LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63 -57
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
_
p
I\ ~
Y
1
ve
r
' I di at N r h rr w
r
R! 1
BENCHMARK: (Permanent reference Point) Describe:,-CK j,' 131i
A'~~lo ~f~
Elevation of vertical reference point: lefe *1 pe at site:
SEPTIC TANK: Manufacturer:— 4 r IL Liquid Capacity
Number of rings on cover Nt Tank manhole cover elevation:
Tank Inlet Elevation: lick Out Let 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;
•brand name of pump
gallon per minute horsepower
and model number '
Type of warning device
Number of gallons-
HOLDING TANK: Manufacturer
Elevation of manhole cover
Type of warning device - feet diameter
SEEPAGE PIT SIZE; Number of pits _
feet liquid depth seepage pit inlet pipe-elevation
bottom of seepage pit elevation f
- I ee~~ -tile depth
_ ngth
SEEPAGE BED SIZE: number of lines-~ width lte.
- _ gth
-
SEEPAGE TRENCH: width ten
,
PERCOLATION KATE 4c" ~s AREA REQUIRED x AREA AS BUILT
INSPECTOR V., " ' -
r
PLUMBER ON JOB
DATED
2 L z F>= t
1.IC1?N E NUMBT:R PL~f•~ _l -
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABl HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
MICONVENTIONAL ❑ALTERNATIVE State Planl.D.Number:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned)
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER:
INSPECTIO D T
Robert Mello R. R. 1 Hudson, WI 54016 .~12-
BENCH MARK (Permanent reference
pomtl DESCRIBE IF DIFFERENT FROM PLAN.
REF. PT. ELE V.: CST REF. PT. ELEV
SE SW, Section 8, T29N-R18W, Warren Township
Narne of Plu mber. MP/MPa SW No..
County Sanitary Permit Number:
Byron Bird 1309 St. Croix 34823
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL
LOCKIN OV
P OVIDED. PROVI _
ES ❑NO
:D :1N VENT DIA.: VENT MATL. HIGH N
WATER
C/ ALARM UMBER OF ROAD PROPERTY WELL BUILDING IVEN TOFRESH
FEET FROM LINE AIR INLET
S NO ❑YES ❑NO NEAREST Uhf
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID AC17V
MP MODEL PUMP/SIPHON MANUF ACTUHEH WARNING LABEL LOCKING COVER
❑YES -]NO PROVIDED PROVIDED.
GALLONS PER CYCLE: ❑YES ❑NO ❑YES ❑NO
UM D ONTROLS OPERATIONAL NUM BER OF PROPERTY WELL BUILDING (VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at th depth of plowing ticrH J DIAMETPR 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 "O. OF DISTR. PIPE SPACING COVER
TREN~CyiE&'. INSIDE DIA. st PITS'. LIQUID
DIMENSIONS PIT DEPTH.
GRAVEL OF PTFy FILL DEPTH DIST H. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. p
BELOW PIP / ABOVE COVER ELEV. INLET ELEV. END NUMBER OF PROPERTY PERTY WELL. BUILDING. VENT TO FRESH
PIPE FEET FROM ?
f~FS 9~ 4J ,~__7/_ NEAREST----ill
. A
MOUND SYSTEM: -
Mound site plowed perpendicular to slope
Chi k the textur of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: d system to make tain that it_ ON REVERSE SIDE. SHOW ELEVA-
❑YES ❑ NO ee s the cri ria for iu sa . - TIONS MEASURED.
SOIL COVER TEXTURE
PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVEHrRENCHBED IDEPTHOVFRTHENCH,eED ❑YES ❑NO ❑YES ❑NO
CENTER DE T F70PSOIL SODDED SEEDED MULCHED
EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF LATERAL SPA NG GRAVEL DEPT BEL W PIPF FILL DEPTH ABOVE COVER
TRENCHES: '
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIP M IFO MATE AL'. NO TR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV ELEV DIA ELEV.' E DIa
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COV MAT IAL
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: /n PERMANENrMnRKERSEYES O ❑YES ❑NO
_I OBSERVATI N WELLS: NUMBER OF PROPERTY WELL: BUILDING
FEET LINE:
lD - ❑YES ❑NO ❑YES ❑NO N
~
5 ;z
Sketch System on',
Reverse Side. county file for audit.
IGNATURE _ TITLE.
DI LHR SBD 6710 (R. 01/82)
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
LNOUSTRY, 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% 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:
~7 L R1K J. s oav
Property Location: City, Village or Township: County: /
a -1C/''/aS /T ;2 N/ R E (or CA 61X
LQt~IVu~nber{ Ik No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
PJ 1 (If assigned)
l
PE OF BUILDING l
Number of
❑ Public* ❑ Variance* ❑ Other (specify)*~- (Syo~ "lOd~-SC/-~ Bedrooms:
1 or 2 Family *State Approval Required. W of
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY vp X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: N/VC°. F
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit
,.~7, ❑ Alternative (specify) ❑ Seepage Trench
_2 7 Water Supply: Owner's Name as Listed on Soil Test Report (If othe th n present owner):
'QT ,4.'1 e a
Z Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signatu MP/MPRSW No.: Phone Number:
AV A, 0 Al
N
Plumb is Address: , ame Designer:
COUNTY/ DEPARTMENT USE ONLY
Si re of Issuin A nt, e: Date: Sanitary Permit Number: APPROVED `r1 g yy O a~ ,j
243 1 ❑
*3 DISA PROVED ~O
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)
1'u ruI - S T C 100
I
Owner of Property.
/~C~~ -it • e j/~,--- - -
Location of Property SeCLion_1_7 N R IL-W
Township _.L k- 64 1?
Mailing Address Lv C'T 1Z
r-~ - -
Subdivision Name
Lot Number
Previous Owner of Property be
Total Size of Parcel S
Date Parcel Was Created
Are all corners identifiable? yCri No
Include with this application one of Lhe following:
.Certified Survey Map
.Deed
.Land Contract, or
.Other Legal Document which duSCrihes Chu Property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No.;t 5-T6 ; and that I (we)
presently own the proposed site for the sewage disposal system (or 1 (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been k cQr ed in the Office
of the County Regis r. of Deeds, as Document No. 1(' -
_
S
Itr 7zr E E OF OWNER S16NAruRE OF CO-OWNER (IF APPLICABLE)
"7
DHTE SIGN
DATE SIGNED
14( e
$ p
13`/
I k It
lC~~
yy~
r
l
Dt'ARTMENTOF REPORT ON SOIL BORINGS AND ,.E 'I GS
I~t DUST(~Y , D N
LABOR AND PERCOLATION TESTS (115)
HUMAN RELATIONS "Y 5
(H63.09(1) & Chapter 145.045) Ira
LOCATION: SECTION: w OWNSHI MUNICIPALITY: LOT NO.: BLK. NO.: SUB 1 ION N
'/a D/a /V9 N/R 1 if (or) Gam. C.A./ of No
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE !N2n I~~ NO. BEDRMS.: COMMERCIAL DESCRIPTION: ON TESTS:
[xttesidence /ew ❑Replace 4V 4ES
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM-(o tional)
~Sau ❑S®u_aS❑u ❑S[M ❑S®u ,~,{w~,ow
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 ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B Z 7" S Z7 B<rs
s~
64
B- FsS 13W t Av-S4 1 f3 Scr Sys'
7 4
gt~/ C~ s rs Sf .r .C s 3 ,~n~Sc~ S' 3
~ - b - ' - $ e- ~.r 6 .5t sue.
a ' o£crt PERCOLATION TESTS
4TESTDEPTH WATER N HOLE TEST TIME DROP IN WAT R t€V.EL-jNr_HES_ RATE MINUTES
AFTERS ~EyLLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
-37
v ~-6 ' U 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 hor,
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 percen
of land slope.
I
SM ELEVATION 9_3..3
w s` x o 00
E
x
k • s • e v v ~ ,
XP x
1~z tN
ORO 7T 4. G ti
C
k ~
w x k
X. X x`
d7 ~i
Q
I, the undersigned, hereby certify t 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 ita recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON
t
1 7. 9
TP,
& j
A DRRES : CERTIFICAT N NUMBER: PHONE NUMBER (optional):
CST AT
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
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Parcel 042-1045-95-000 07/06/2005 01:16 PM
PAGE 1 OF 1
Alt. Parcel 17.29.18.261A 042 - TOWN OF WARREN
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* MELLO, ROBERT L & LUCILLE
ROBERT L & LUCILLE MELLO
1046 100TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1046 100TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 2.400 Plat: N/A-NOT AVAILABLE
SEC 17 T29N R1 8W COM NW COR NE NW, TH E Block/Condo Bldg:
20 CHNS, TH SW TO PT 5.52 CHNS S OF POB
TH N TO POB EXC PT TO PARCEL DESC IN Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
995/603 17-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 995/603 WD
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: n Last Changed: 10/22/2001
Description Class Acres Land Improve Total State Reason
OTHER G7 2.400 39,500 128,000 167,500 NO
Totals for 2005:
General Property 2.400 39,500 128,000 167,5000
Woodland 0.000 0
Totals for 2004:
General Property 2.400 39,500 128,000 167,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
Parcel 042-1021-50-000 07/06/2005 01:15 PM
PAGE 1 OF 1
Alt. Parcel 08.29.18.124 042 - TOWN OF WARREN
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
ROBERT L & LUCILLE MELLO ' MELLO, ROBERT L & LUCILLE
121 LONG MEADOW LA
ROTONDA WEST FL 33947
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 14.640 Plat: N/A-NOT AVAILABLE
SEC 8 T29N R18W SE SW EXC PT TO PARCEL Block/Condo Bldg:
DESC IN 995/603
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
08-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 995/603 W ID
2005 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 07/11/2003
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 11.640 1,500 0 1,500 NO
OTHER G7 3.000 18,000 33,400 51,400 NO
Totals for 2005:
General Property 14.640 19,500 33,400 52,900
Woodland 0.000 0 0
Totals for 2004:
General Property 14.640 19,500 33,400 52,900
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
DEPARTKENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
j II'rDUSTFwY, C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 P.O. BOX 76
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
ELOCATIT:44 SECTION:TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. O.: SUBDIVISION NAME:
'/a /T N/R E (or) W E : OWN/BUYER'S NAME: MAILING ADDRESS:
n
USE DATES OBSERVATIONS MADE
0. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
❑Residence [:]New ❑Replace
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 as ❑u ❑s ❑u os ❑u as ❑u
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER N. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- C! . j ! e
~ ! r
B- Z lt3 CIS, c a ( ;S 4
`
B 75-
L 4. ' C 75 1 ,r A41 y AV "
` S
7- rt 1.
7. e?
l 4, s 14
C ( l' `a l / c'
PERCOLATION TESTS
TEST DEPTH WATER ,IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER IA12#ES AFTER ELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PERK INCH
P- 13
1 44 ~1111
P-
P-
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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.
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SYSTEM ELEVATION a i d
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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 the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION N LIMBER: PHONE NU MBER(optional):
CST S,LG1VAy E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. -
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1=P;ikflTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
)USU RY, DIVISION
A\ID
PERCOLATION TESTS 1115) MADIP.O.SON, WI BOX 53707
1MAN HE LAI-IONS ` J 7969
3707
(11163.090) & Chapter 145.045)
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IOWN,,HII/MUNICIPALITY LOTNO..BLK.NO. U:1DIVISIONNAME:
_'/4 1/4 /T N/R E (or) W
tUNTY: OWN TBUYER'S NAME: MAILING F DDRESS:
t
E'c ~L G<</ U ✓ ltJrSC
- fd ----DATES OBSERVATIONS MADE
O.t3EDI NIS.: COMMERCIAL DECRI-P-TI-ON:_ rO LE DESCRIPTIONS P ERff~A TIO)Re❑New ❑Replace~ ikTING : S= Site suitable for system U= Site unsuitable for system
fVVENTIONAL MOUND: GROUND PRESSURE: SYSTEM-IN-F1l_L HOLDING TANK: RECOMMENDED SYSfEM:(optiunal)
❑sau ❑s❑uIN os❑u ❑sou as❑u~-___-- _
i'un:olation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
udar s.HG3.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
1Jr( ~f PROFILE DESCRIPTIONS
)RING DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
UMBER .N. ELEVATION OBSERVED EST. HIGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
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Q ~ 49 ,
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14, A4
PERCOLATION TESTS
TEST DEPTH WATER N ROLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
CUMBER INe''Ll AFTER ELLING INTERVAL-MIN. -E- R- ITO Rloo 2 PERIOD PER INCH ;21 Nu Y/ 3 0 .37
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L-OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
vital 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
land slope.
.OYSTEM ELEVATION 93,
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
,dinuustratrve Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
DAME (print): TESTS WERE COMPLE f ED ON:
f
ADDRESS: CERTIFICATIOPHONE NUMBERIoptional):
CST ~AN E:
r .7
DISTRIBUTION: Original and one copy io Local Authoiity, Property Owner and Soil Tester.
UILRIi SBD-6395 (R.02/82) OVER -