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HomeMy WebLinkAbout032-1024-80-000 n 0 O n cn O 'I 3-0 n r~ d `r1 o m f o m F~ m o ~ m CD c m Q 3 r+ fD m CD CD "a A~ H• v (D m o 1 CCl)~ pj N N CNn O O~ 0 O N 0 O O H O p .((O °w `C (D o o m m o a o CD m rn CD a m n a N o 0 CD n O o O N O W W O a) CD QJ O Cll CCD CO N O CD CD N y 3 v Cn ,Z J, '1:2 0 S O CA Q (DD CD O N CD CD N O -1 CD O CO Ln C C4 n N CD 0 N m b A~ 3 o W CL W A 0 l~ -I,. 7 N_ N O 2O VI c '•7 !V C _ to < ~ D a Z D a s C) (D CD ca CD (n d Cam' D Cn a W CD M CD C:) 0 0 CL C:) CL S2 W CD _ 3 z CD CD CD (n N N co co N CD ° N N cn -0 V -0 O O O O O O ° cn o cn o o' ~y,~ 3 cn cn ai cn CD J cn tcn rn C n o W D CD -1 zs m O O - zT -0 0 0 q (D CD - 1 d 1 L cD CD M CD (n W CD N z z -i z z co z c _i D O D CD O a O > > O 3 tr 0 -U O s cn T • (D (D CD (D CD .Z7 CD Cn Z7 ~ rn M. F ° ° CD ° a -0 N (n d ° CL w n 3 CD E Z CD CD o u o m o' n c c :3 A Z o ° a a 6) o. ° Z w m ao v W v m a CD CD (D a z o C M ~ 00 3 a * cn m (D N z W z < CD CD CL cr~ cn D N ° D (D CD Cn CD CL CD S C1 CD a `G 'a C1 N cn n f_l CC N C CD G Q CDj (D O T y C.) O~ "n CD = (n N C N Cy CD N o m 3 Z a C~ N o a O a- v 0 U) - Z) CD ° O c O Q' 7 (L] C- S CD r- ow 3o O N A CD Cl N CD C1 M N d m C M O C(n (n N O CD 0 3 CL CD CD a w a o a n c CD N n m CD 3 0 ° N c a o CD oa CL a b :3 :3 CD CD Dro v rn O E» O w ~n ° 0- ° a. ti Parcel 032-1024-80-000 11/15/2006 01:56 PM PAGE 1 OF 1 Alt. Parcel 9.31.19.124E 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): O = Current Owner, C = Current Co-Owner O - NEWTON, NICHOLAS & JENNIFER NICHOLAS & JENNIFER NEWTON 2234 50TH ST SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 2234 50TH ST SC 4165 OSCEOLA SP 1700 WITC Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE SEC 9 T31 N R1 9W 3A IN NE SE LOT 3 CSM Block/Condo Bldg: VOL 3/619 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 09-31 N-1 9W Notes: Parcel History: Date Doc # Vol/Page Type 07/10/2006 829271 WD 12/14/2004 782460 2714/441 EZ 12/14/2004 782459 2714/440 WD 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 57,600 204,900 262,500 NO Totals for 2006: General Property 3.000 57,600 204,900 262,500 Woodland 0.000 0 0 Totals for 2005: General Property 3.000 57,600 204,900 262,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 316 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 pppppppr o cn o 3-0 n d 0 (4 af 0 mf 3M3 o ((D 3 (D 0 0 -0 ' (D 3 ' 3 _ 3 v v 0 o ° w° o m w o_ o n o 0 CD ° C • c c ° 3 w r- w o o E: (D v4D o m n m N M G) N G7 (n o _ co co : N CD W C CCD A ! ° (D v v (n 3 m 0 ►s O (fl Q Q Q N N 7 CD n N 4 A O O ° c (D n _ w 0- $ w m o A 3 7 N A O cn -n d CD m m to D a s u> Z D A s cf) _ Cp m N C. a D N a 7 W C N h m o° N CD c ° CD 0 3 O O C/) 0 0 Op CD N (D 3 j 3 (A CD CD CD CD Z (D N 0 C- (n N N co 0 N 00 (n O C v: v v ~ A O O O 41 41 COC OCC C O C U, d (n 'D G G G N C -0 -1 N W Z O C~ C (n fn (n 7 3 Vl fn fn (P O D 3 Fn CD LJ C) CD D 7 "Cl) = CD (n D N A) cn N N r 9 d (D Z K i w Z -I o ZD co 00 0 D ? 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SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 OW EVERYTHING WITHIN 100 FEET OF SYSTEM i th Arrow ` a ;e oa I di SC L BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site:` - SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings on cover Tan manhole cover elevation.:- Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set or a cycle gallons; total-capacit_y 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 Typpe of warning device - SEEPAGE PIT SIZE: Number o pits eet iameter feet liquid depth seepage pit in et pipe-elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines width length tile depth-- SEEPAGE TRENCHtC width length _ PERCOLATION RATE REA REQUIRED REA -LT 1 INSPUT DATED PLUMBER ON JOB _y - LICENSE NUMBER U` DEPARTMEWT, OF INDUSTRY, INSPECTION REPORT FOR v1-:,)_ SAFETY & BUILDINGS La80R & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 t BUREAU OF PLUMBING MADISON, Wl 53707 CONVENTIONAL ❑ALTERNATIVE State Plar,I.D.Number Ilt assign edl ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTION DATE BENCH MARK IP r ent reterence point ESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV . d'1 yc -3 rl 19 m rd E-11 N~iine of Pluinh>er_ MP/MPRSW N,, Couniy Sanitary Permit Number. ie SEPTIC TA /HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKI G.f;Oy / PROV TOED PRO DEAD . `I 4~ ES ❑ NO YES ❑ NO BEDDING: [IDIN T D IAVENTM TER NUMBER OF GOADPROPERTY WEL BUILNG J VENTTOFRESH ~'f ALArvM ) FEET FROM ! LIN r YES ENO E£Y U NEAREST ~CG /tr L 2_.4 AIRLEr OSING CHAMBER: MANUFACTURER BEDDING LIO D ' CIiV PUMP MODEL PUMP; SIPHON MANU FACTUHEH WARNING LABEL LOCKING COVER e PROVIDED PROVIDED. EYES N EYES ENO EYES ENO BUILDING v TO FRESH J ~ENT GALLONS PER CYCLE: PUMP AND C ONTROLS OPERATIONAL NUMBER OF „u)PFHTV wFLL (DIFFERENCE BETWE(FEET FROM " aIR I NLET PUMP ON AND OFF) 1 EYES NO NEAREST -0 SOIL ABSORPTIO ST Check thhe soil oisture at the depth of plowing ~I m.,h) I H MAV RIAL AND MAHKINr, or excavation. (If it can be rolled into a w re, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF DIS FH PIPE _j=AC INS, GOVEH INS 11 IA mLLI LIQUID BED/TRENCH ; HEN' Es anrl: PIT DEPTH DIMENSIONS j -l~- I- I FI i I)FPTH H PIVf DISiH PIPE DISTR-PIPE MATERIAL NO DISIH 4 NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH f,f I EmsIf ;)Vf CL)UFH FIFV INLET ELEV ENO PIPES LINE AIRJ~pLET. FEET FR NEARESTM Sa /~It~ ~s.~~S"z MOUND SYSTEM: Mound site plowed perpendicular to slope C ec the texture of the fill aterial for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: ou d systems to make ertaim that it ON REVERSE SIDE. SHOW ELEVA- mee`ts the criteria for medfum sand. TIONS MEASURED. EYES NO SOIL COVER rFxwHE Pe vMANENT Mn Hs oasEHVnnaN wEI Fs tf! EYE ENO DYES NO DC PTH ()V FH IHE I C I I R1 D DEPTH OVF H THEW Il RFD; U 'PTH OF TOPSOIL 5(7.11) E1) Sr EDFD IMIILCIII D CFNTFH EDGES DYES NO EYES ENO EYES ENO PRESSURIZED DISTRIBUTION SYSTEM: '')I ii LENGTH NO OF 7L-SP ING GRAVEL DEPT E )W PIPE FI LL DEPTH ABOVE COVEH BED/TRENCH rRENeHEs DIMENSIONS ANIFOLD PUMP MAfvTOLD ISTR. PIPE MANI LD MATEHI L NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAHKINU I IEV ELEV. DIA ELEV. PIPES DIA.: ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED OLE SIZE HOLE SPACING, D.'ILL EDC HHEC:I LY CO EH MATFRIAL PLAN'S INFORMATION YES NO _ DYES ENO COMMENTS. PE RMANENT MAR ER JOBSERVATION WE LS: IN UM BER OF PHOPEET FROM S NO EYES ENO EAREST- C. S~ j. I 1 Sketch System on ' Rata+ my file for audit. Reverse Side. SIGNATURE TITLE DILHR SBD 6710 (R. 01 /821 r DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR ANP PERMIT P.O. BOX 7969 HUMAN RELATIONS (PL13 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. The owners copy or a legible reproduction of the soil test report must be included. Proper wner: Mailing Address: 10 1 4a v I Y, Property Location: "City, Village or ownship:•; ' County:- L S T,;;'/ NiR T_ (or) W Lot Number: Blk No.: Subdivision Name: Neares Road, Lake or Landmark: State Plan I.D. Number: (if assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: L71 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 HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: y t?v , ' EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ;&New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit 3 ❑ Alternative (specify) Seepage Trench Water Supply: ~~C•~ Owner's Name as Listed 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 lumber: Signature: , M MPRSVy o.: Phone Number: ,(Z/- i Plumber's Addr ss: /Name of Designer: COUNTY/DEPARTMENT USE ONLY Sig ure of Issuin Agent: Fee: O Date: Sanitary 29-APPROVED Permit Number: ❑ DISAPPROVED I `J Reason for Disapproval: Alternate course(s) of Action Available: nqe of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to i Failure to comply will void the sanitary permit. 'te-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,' c DIVISION LAB-OR AN, P.O. BOX 76 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 t (H-63.090) & Chapter 145.045) LOCATION: SECTION: D 6 W OWNSHIP/MUNICIPALITLY: LOT NO.: BLK. NO.: SUBDIVISION NAME: 1/~ 1/4 c / " g_ (or) n CO N Y: O NE BUYER' NAME: MAILI'N}G ADDRESS: f USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: [PERCOLATION TESTS: Residence &ew ❑ Re lace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: j -GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) NS ❑u s ❑u ~s ❑u ❑ s ®u EIS ®u If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.1163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 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 A k, ' B- ;,o 1611 -5 T, B- _5 B- 7e, 'Z '6'r o B- 7 - ~ r~ ~ _5.~ . "fir •S•; `'fi'r - C`-'.~ , V 7/ '7,/*, IP /h C --7,7 'PERCOLATION TESTS 7'~ TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ I _7i 4> G~ < P_ 7- 13, P- ..3 P_ IM f3 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 locatio lot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION . cl B, inn, 0- r - - - fig' E ~Q E +'I V _ Z 1 5,40 ;4,1 ti 17 . P -ie 6-k, 3 [ 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 (print)~: v TESTS WERE COMPLETED ON: l71,64!'y ( 9- ' ADDRESS: 1 CERTIFICATION NUMBER: PHONE NUMBER (optional): C 1 CST SIGNATU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DII_HR-SBD-6395 (R. 02/82) - OVER Ms I Awn, no Not 02, "A" I FvW 1 F°r t { tr and f, f..''.. Y pie i? ,"0'.v ratrig boxes. A .fi i'''{F f,S _ LO .i AM . ? . i ` R RUL L ,sip I GAS , s F r<< - 01 s M AK " we M abb .u°2; s m Amon hoe tts- n < WO, C:i£.xv 0t,i, t . NOW _ vs :W -F, Vc. r a L aFi _ _ MWIV mot; c' €~TF and m e Fs C. .y 'n a to W._a d. to dawn o_e.s, sdf c ,o nle, lata„ 10, i, Avon sig... p um a, MKI pini`. overt€o ) A . no °PQ, pow WA. in the aprouj z3'. 't ` ( ,._~_t ~j ..Ism 4 ,A, C_.'. " ) : ~ e s ' - S;i nF ` €`v' - x.73' Mvdim-,~ sandl VV 100 Fine S,old My top' Ali GY My Low! '.i S x Q T i n !.r.usn, R - Loy SON loan "Wown ..e i "to l '3li Cnihn lost s hin slenrKyj x sav"ary _ z . cmull; or , „t' the ,}uz narna to ei ,_C:ali, l; o M .--i. t F i. 10 6,11 ,.a s.,,.,. ur , 3., o,, won 1rt c}i l I 4jl to s , cc.5 ~ ti r. xJ~/ r AL -94 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LAtOR & hi'UMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADIFON, WI 53707 X CONVENTIONAL El ALTERNATIVE State Plan I ,D. Number. (If assigned) ❑ Holding Tank ❑ In-Ground Pressure E Mound NAME ERMIT HOL ER ADDRESS OF PERMyTy OLDER. INSPECTION DATE 1 JJ/~ BENCH MARK (P ,m reference poi DESCRIBE IF DIFFEREN 41M PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. ~f Name of Plumber. jrIPIMPRSVI No.. unty Sanitary Permit Number T 11 ` SEPTIC TA K OLDING TANK: MANUFACTU E LIQUID CAPACITY. T AK I LET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: OYES ONO DYES ONO l j( WELL. BUILDING (VENT TO FRESH BEDDING: VENT DIA. VENT MAT L. HI' WATER NUMBER F ROAD. PROPERTY MES LINE. AIR INLET. FR ❑ YES ❑ N R A FEETO O Y ❑ N NEAREST _ DOSING CHAMBER: MANUFACTURER JBEDDING. LIQUID CAPACI rY VUMPM/E JPUMP/SIPHON 1ANl1tACT UH EH JWARNING LABEL LOCKING COVER \ PROVIDED. PROVIDED: EYES ONO OYES ONO OYES ONO IVAIERNIT FRESH GALLONS PER CYCLE: PUMP AN LS OPERATIONAL. ER OF PERTY WELL JBUILDING "LE T (DIFFERENCE BETWEEN I F ET,FROM NE PUMP ON AND OFF) OYES ❑NOf ' NE REST SOIL ABSORPTION SYSTEM. Check t e soil moisture at the depth o plowing t vt,r~l - uI~n1E rER MATERIAL AND MARKING or excavation. (if soil can be rolled int a wire, con truction shall ce se until RICE the soil is dry enough to continue.) IN L CONVENTIONAL SYSTEM: ; WIDTH JLNO. OF DISTR. PIP SPACING, 'NT E INSIDE DIA. -PITS. LIQUID BED/TRENCH THE HE E IAI: PI DEPTH DIMENSIONS C1HnvF! DEPTH FILL DEPTH UISTR. PIPF DISTR. Pi E DISTR. IPE MATE L NO. S H NUMBER F PROPERTY WELL rILDING- VENT LE FRESH BE LnW PIP[ S ABOVE COVER ELEV. INLF T ELEV. E PIPES FEET FR M LINE AIR INT- NEARES MOUND SYSTEM: Mound site plowed per ndicular to s ope Check the exture of the fill mate for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upsl e: mound Sys ms to make cer t it ON REVERSE SIDE. SHOW ELEVA- eets the cr teria for medium n TIONS MEASURED. ❑ YES O SOIL COVER. TEx TURE RMANENT ARKERS. ~UBSERVATION WELLS YES ONO OYES NO DEPTH OVER TRENCH BED DEPTH OVFR TRENCH; D DEPTH OF TOPSOIL DED SEEDED MULCHED CENTER EDGES YES ONO OYES NO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: _ WIDTH LENGTH JNLATERAL SPACING. G AVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS M11ANIFOLD PUMP MAN IF STR PIPE MANIFOLD MATERI NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEv ELEV. DIA. ELEV. PIPES DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING RILLE ORR ECTL COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS E-K ONO OYES ONO PROPERTY WELL: BUILDING: COMMENTS: PERMANENT MARKERS: ;7VATION WELLS: NUMBER OF I_ 1 FEET FROM LINE DYES ONO OYES NO NEAREST- i Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE DILHR SBD 6710 (R. 01/82) APPLICATION Pp. DEPARTMENT OF ~SAI+ETY & BUILDINGS INb0STR''Y,' FOR SANITARY DIVISION Y c .O, OX 7969 LABOR AND PERMIT P HUMAN RELATIONS (PL13 67) ZON, WAC)ISON,, 1 53707 FiC Attach plans for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dime 'oned or drawn tosca Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical ch cteristics as spe ' led in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the desl esigned by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Property Owner- Mailing Address: <:7/ v~ ! f Property Location: C.Ly, V t SM cownship: County: E '/a.5L %S'/ i T-3 / N/R X(or) W .tea r,--o ~ 115 - Lot Number: Bik No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) i TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. V TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 1- HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: c 1 C3 EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA ~7I (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit / ❑ Alternative (specify) 2~ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): X. Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of tuber: Signs ure: /MPRSW NO. Phone Number: Plumber' ddres . Name of Designer: COUNTY/DEPARTMENT USE ONLY Sign ure of Issuing A t: Fee: Date: APPROVED Sanitary Permit Number: ZZL,~~f 1 1 DISAPPROVED 64 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 (N.03/81) DEPARTMENT OF REPORT ON SOIL BORING d`/'" rlQ~- SAFETY & B DI LDINGS INDU~TR IVISION Y•, .y LA60R AN P.O. BOX 76 HUMAN PEDLATfONS PERCOLATION TESTS ( ) c' MADISON WI 3707 LOCATION: SECTION: TOWNS HIP/WA+H+G+RA~y: LOT . NO.: SUBDIVISION NAME: A) C /T N/R/ E(or) 1,- COUNTY::: OWNER'S DYER' NAME: MAILINGADDRESS: a _64 - USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER~!AL DESCRIPTION: PROFILE DESCRIPTIONS: JPER LA ON TESTS: esidence lxvew ❑Replace '4 j / . F- C - - PjZ C~ RATING: S= Site suitable for system U= Site unsuitable for system 2 6'0<S2_ CONVENTIONAL: MOUND: t' IN-GROUND-PRESS IURE: SYSTE~`M-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) J ®S ❑V LL]~J ❑Y ❑J ❑S ©U CGA✓Fn-ho iRl C~ ter r~ 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: I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OB ERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ~ o B- Ivoke 7 '7 ~7 `y S aC../.7'~~Sn.S`.~ 1,0 B- Z '7 5 B B- 5- gy no f) 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 6 a P- K''.3 P- - 3 3 f Co < 3 " y 4 P-3 _36 "-'7 H- 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. i o ; SYSTEM ELEVATION 9,q '~j A . f q p-329.;F 5 L P-3 0 P 10 4 N6 13 3o' (o ca' Ze' 28'7' 6~ 4 „r m J SAC &A7, 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): /.s ue - W8 /2. 4 har e- Or- A~ tc~,` 1 CST SIGN TUR : DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) You l f c