HomeMy WebLinkAbout022-1070-70-100
,
0 0 9 v n
e m F c W- p
N m a
CD m ^
I CD 3 ~ ~ y \ 1
~ a m o p N •C
CD M CD CD
V) 00
N C p p i0 7 O
CO O- n 7 7 n N O O
OD O C CD
U7 O) 3 O W °
N_ N A j ° ° C
O <D O !r
CD U) CL a m
/ W m
n o o cfl
J ) 3 co CD ° ° 0 lot
CD
a- N)
0
CD o r- cn
OD co r-
N) N) CD
T "u -0
V
o O O O
O n v < A z +4
G~ C\ ~c cn cn coN D
cn
CD d=
5
;o
7 N N A
V O N
N =r ~ N W
n ~1 z
° z co z
CD C CD
U1 v C4 CD (n
i r CD
\
~ N
C (D N
W ~ a
7J n p z O
Q v p) CL 7
o= (n - i N)
M N CJl
ca (D
z
fD ~ ~ z
Cn CL 3 A l
7 E 3
N z
\ N A
W
v D
c C, a
a
3 -
CD O y -n
Q' O (n
77 N C
S OZ G
O _ z 0) cn
3 i a y
(D ] O ~
f:C" 3
O N
N 7 O
i p D_
o m c r
CD o
t < CD c-)
n
(D j O N
4
V S O N
03 0
o
Co
N
A
N Oq
A
E» O r N
° b
00
w ~p1
3 m ' o 3
m (D 'B
v fD w /wt~
3
(n Z N O N N O <i •
n O O ~ 00 M v ~ CTI N }~~11
3 n m A
w 'a Z CD 4 O co o
N C T
N O CD CO O C.
N C1 NO u~ O W R
Co O C COi N N O O
-i W 1
al m CD
cl O _ Q O O Sit
u 7 fn O O rr P~
N fA A 7 ~
C j
C'i w CD O
D C
(D (D p m
T N W `D
OD o °
3 C)
m
u (D N O
N oo 00
O C
N N CD 6 !V
_ Z7 '0
to N w Al
z 0 0 0
C C C T
O D G G G N C A
m ~ z
- CD v o
- CD
0 - 7~ i~
: _ a ~c N
w
7 p
(D A
N S N
C (Njl
CD
z
z W N
O Z W Z
D cD O
Q
y ) Z
s
O ((DD CD CD
7J -1 cn !V
(D w C /yam
C (D (D
W D
d ~ O
Z 2 (Q
O O P 7
C: ;o
Z O
Cf)
M ~
M N
W N U
C N z
O_ Z
O Z
N Z
O A
W
O C O N D
O C 7 n G C
? G
A W C (D (D
N O N T
O ti ❑ C
O O O
N O Z --i IvO
O- O
O O
O O O
D O O
OT 0 7 C r
W
C,
CD-
C/) C O= 7
S _ (Q
A O (DC7
N ? O
O N 0O
C O
6
v, a
(D IC ~
~ dC
O C
O O
DEPART,I I , OF REPORT ON SOIL BORINGS $ I SAFETY & BUILDINGS
INSTRY ~ DIVISION
LAE RAND PERCOLATION TESTS (1 P.O. BOX 7969
HUMAN RELATIONS ~y CF/~ DISON, WI 53707
LOCATION: SECTION: TOWNSHIP/ Y: LO :BLK. MOP 10" ME:
i= Vii' v c
COUNTY: 6WPWS/BUYER'S NAME: MAILING ADDRESS:
USE DATES`&ft03j -b ADE
S Residence BEDRMS.: COMMERCIAL DESCRIPTION: R NS: ER A ION TESTS:
SResidence XNew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDED SYSTEM: (optional)
QS ❑u aS ❑u oS ❑u ❑S ❑u ❑S ❑u k Nyr=FN+rlom
NOT C COAANA =v f. Cam/ ~f i E A i- IT r+ G o f' - o ca Al L -rtC .V/hTz _ r T c
If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL If any portion of the lot is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
ST ~2niX rc 5 P`^O l#tSF= 7 = PROFILE DESCRIPTIONS .F5
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.)
't I31 L '(5y 1 ~ih S 5/'~ $n, ~n Y V-Ir
B I 7Z- A- /V i~F FS > 72 PEA t~{ ~ 5~ 2 ~ " t l Fs'~ i~ ~ 'iL fem.= wsFSi+ F b ins ~ n/ L4Y~= ~S
&i I_ T` j F n 5, 34 B v-t v 4-4
B- 2_ a %,,5- 1Y0 A.I,F- 7 a
t'~L L i`sjz2"-; DkVi.~ $n v{-S~ ~~5'j 4rrr r=- n vIC S,zz
'L~4V k_ V FS, kt~t g e% 0, rv i rH
$i L 75, !•j ~4f-~ Q1 V r- $,'3G..j F'_GL t?YS ~/'FS vV/'rt4
B-5' 7L9 Gj 7,C, ~jv/v1E 7 7e ~r Cie j4•~ \/1/ra : - L'i2 5 %
C3~ L 7'S, I" j rtitr. LS n r1: `s; '3 a j Qd 6 n V S i rrf
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 c 7y6 13M 7
P- Z -34 Q"L F_ y 1 / /S
P- q
P
P_
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 5 s 9
"APPROVED"
L/
Dates
0 1=a-P_c6e_r~ ,04.r ra_~r Inspectors --,J g
i c
'r/0 Al
_ . - Iy~ ,
' l nµ I . I~C7(t- 'VG yC/ ~{p /lam(
57C, J . t.0
1
a L~ 1= l~~ C Fl Mh2K-= v Q
`g (Tc ap >7(f S' .0 39, L7 F= !-h C- • Gd_ ; ( ob r 0 ~J
122 X -7 f
A
i, 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:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional):
C St NATURE:
DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owners page Soil Tester.
DILHR-SBD-6395 (N. 03/81) 1
n N O 3-0 n d _ 1
o f c lu o
~ m m n ~ v ~
~ v .0 gt c : 7
~ O
(A -i z O N N O (y
0 p~j O N p CO N O' (n r) << j~
3 N N
D 00
00
\ Q z n N v M
N (D O U o = O 'O C 1
O a 7 ~ f7 O v O
n N O
O a Ooi W O M
7 O O O.
fn (n
f7 m M w o
m m m o. a m
C: CD
V l!
3 -4 -4
+.q-- O N3
N j ~
.J rt a
pz CD CO o r cn
`i O O O Y~
Z
0
c:t
U
fn fn fn 0 D
rc3: < z
a v o v_ C
•r' I~ O y C O
1~ = O cn
_4. 3 CD _ a
Vi C)
Pi PI)
(D CP
z W z
h. C = y CD o
v O °
0 C/)
v~
0 p Q
0
- N
+~J} ro m 5
~n CD U)
w m D1
a
p A Z <D
N ? 3,
Z O
v
r^
oM N
M
W Ut
" co
, z
O
t 3 co
z
CD
T fD n
O O CD d li
a
m a~
N D1 p
7 -n
o v
O' p < Z fl
W p N O
O N m
CD O co
a a
~Qn
a n H
A ' C
m<~ Cj
CD
CD C c~j
5,3
~ m a
m
3 z
N ~ N I
i = rn
I
N
O ~
• - N
a O I
~ O
b i
O
b
S~ N
'69 O
° a
ill
o
a ~ ~ Z o i-
k ~1 r1f~ i ~ir1Yl 4e l
o a x v 3
3 ~
Z
~ ,fig o O P
o~c c
eop th ~
z Oro ,
e y_ j i ~O
4tk
r j m
o ~1 a t~ ;C
a
S ~ ~l
Irv
rn I t~,
1 - !C i
? t;/8 c
Q!, th
C' .
_ E,vsT PQoPE~P-rY 1. ivy \
Z o
t~ Al
y
46
c rn k- A A
~ a
Q°o h ox v
3
U , /Ifj ' r
O p\ 7p ~
OOV OtC lh 1
o C
\ r , C
~ Z
' a
f 10
i
61
; a0
z W bm ~ ~ ~3 r J ii ~m
r ~ (it
V-A
G
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS ~r- DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, Wi 53707
I~CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
Ilt assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE
r ss 'u
BENCH MARK (Permanent re ce point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT, ELEV.
nu_) 7-)er. IQ 13 11 IC,!)A1 ~
Name of Plumber. { )en net h IMPIMPRSW No.. County Sanitary Permit Number:
T vyl T P liSEPTIC TA K/HOLDING TANK:
MANUFACTURER" LIQUID CAPACITY. TANK INLET ELEV.'. TANK OUTLET ELEV. W RN G LABEL LOCK( CO ER
P DED. PROV D
c1 '
C C~ YES ❑ NO S O
BEDDING'. VENT DI A.. VENT MATL HNBER OF ROADPROPERT WELLBUILDIVENT T FRESH
ALINE AIR INLET:
FEET FROMa~~
YES ENO S NO NEAREST. l •Y t
30-
OS NG CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP dh/rP;SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED
DYES ENO EYES ENO DYES ENO
GALLONS PER CYCLE: P PA Dco raoL oPE AnoNAL NUMBER OF IvoPeRTV we u_ BUILDING IVENTT0FRESH
(DIFFERENCE BETWEEN FEET FROM NE AIR INLET
PUMP ON AND OFF) EYES 1:1 NO NEAREST
SOIL ABSORPTION SYSTEM. Check the so mois eat the depth of pl ing LI vnT II ~)Inr,11 TER MATERIAL -IND MARKING
FORCE
or excavation. (If soil can be rolled into a wire, construction shall ceas until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO.OF DISTR. PIPE SPACING COVER INSIDE DIA LIQUID
BED/TRENCH TRENCH S r aIAL: PIT DEPTH
DIMENSIONS ! ii
GRAVFI I)FPf'I FILL DEPTH JUISTIl I PE DISTR. PIPE DISTR. PIPE MATERIAL- No_DISTR NUMBER OF PROPERTY III WELL. BUILDING. VENT TO FRESH
HI lf)w PIPI S ABOVE COVER ELEV. INLET ELEV. END PIPES A LINE AI$I T.
FEET FROM f VVVVVV\\\J\\\J
NEAREST-sL7 /
MOUND SYSTEM:
Mound site plowed perpendicular to slope Chec , he texture , f t4ec aterial for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mo nd systems main that itON REVERSE SIDE. SHOW ELEVA-
ets he criteri for mTIONS MEASURED.
EYES ENO
SOIL COVER. TEXTURE j PERMANENT MARKERS. OBSERVATION WELLS
j OYES ENO DYES ENO
DEPTH OVER TRENCH BED DEPTH OVFR TRENCH,BED D - PTH OF TOPSOIL SOLDE SEEDED MULCHED
CFfviEH EDGES J
YES ENO DYES ENO EYES ENO
PRESSURIZED DISTRIBUTION SYSTEM: _
WIDTFI LENGTH NLATERAL A ING R L . PT BE OW P FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS I
MANIFOLD PUMP MANIFOLD DIS PI NIFOLD ERIA NO. DISTR. ID:STRPIPE DISTRIBUTION PIPE MATERIAL&MARKINGELEV ELEVDIAEL VPIPESDA.'.
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING; DRILLED COHHEC LV COVER ATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
EYES NO DYES ENO
COMMENTS[ PERMANENT MARKERS: ~/JOBSERVfION WELLS: NUM:EST-
2- ER OF PROPERTY WELL BUILDING.
FEEFROM LINE
❑ YES E NO Oyu ❑ NO _ NEA'. 3 2- Gd a,
~'ZZ f I 3 10 - ~~.1.~
Ptt
AA
jop"Ill 2-
Sketch System on to n in my file for audit.
Reverse Side. ~ ~ ts-',
WIli IGN JRE + TITLE'.
DILHR SBD 671 (R. 1A /82)
( ~ 6e CVl CC~ Q J tf LIG .vL K< vlfixcti4,-.
i ,
00
•4
_ ~ J •r-I
c4
00
cy~
too N
V ~ Q~
3 l
J
et ~
C t/a %S ~2S-/T a1 N/R jS fir) W )~/d.'~Z
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
( 1 or 2 Family *State Approval Required. 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: 211~4 S y E C.
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): LP IVew ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit
0 ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: ( Owner's Name as Listed on Soil Test Report (If other than present owner):
rivate 1:1 Joint El Public
I, the undersigned, hereby assume responsibility for installation of the pr) ate sewage syste shown on the attached plans.
Name of Plumber: Signatu MP/MPRSW No.: Phone Number:
~k~r~ e5::r:, c>r r;•:► T t' 1~~~1 (~~Z) w3°3 •z5~-1
Plumber's Address: Name of Designer:
h'~~r`►*~~Tt~tvlc.n 3~.y'0 M~Nr~'•' tik-~a. Nnl ~ 3H 3 K~v~~~-~..~ 0. ~R+~t.sL
COUNTY/ DEPARTMENT USE ONLY
Sig ture of Issuing Ag t: Fee: Date: ❑ APPROVED SanitarycPermit Number:
Go - 00 ~ ❑ DISAPPROVED ~ G
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
I LHR-SBD-6398 (R.07/81)
D
t
Y« A
7 .t.
Ao 111 11
k 0
7 'r-
A
a ,cam ~ •
n1 x
(At %
to ~ ~ ~ • r e ~
F
~b ~X r
x
* t1
r ~
„ 3 . y..I
rr.
PIt-
TIC
0 _
v
u , W 0
o _
Z} k-- ?
- IIN
a
I
r
,r
t ` `
t