HomeMy WebLinkAbout036-1084-60-000
• n CO) O 3 T n d ~1
0
C
1
T m m
w 2 2 Z G) Cn w o ~1 •
0 y N M N 0 io a> O ~ iv c) `C SrJI
N 7 O O C fD ('D 7 ~ o"
W
v d' O_ O_ N v 0 7 j O 0 1
N = W CO N 0 j
Q O m
0 3 O Q 7 o
co O
O
N 01 p C
W O C'!.
v cn D - a n
(D (fl CD N C.
N
3 a W ° rn a
O O N
CL N z
N
C OD~ C:El n o c
OD 00
N
P
O
N D v v 3 cr•
z 0 0 0
O 0 p a
n C N N N m
I
CD 'a v
v v N
CD
~ n d v o ' 90
= m a
D1 N V C
N 7
CL
a ~ N N
z w z o
0 D m o
n0i O a
CD N
O N ,III
C CD C.
CIO a
d 3 7
z D (D to
O O p A? CD
N C rr
_
O) A
O 7
O
Cl) N
C
M CD
C
Q Z
p 3 A ~7
3 c
N m
M a
I ~
m
a a C 3
X G 7
O 0
:3 T
m
a Z a
n o
N
s
I ~
z
I A
I
a
I
I A
I ~
i
N
O
O
V
A
O_
O
Dp N
< ft
H
cfl O
O o y
O CL
~
Parcel 036-1084-60-000 01/11/2007 03:51 PM
PAGE 1 OF 1
Alt. Parcel 32.31.17.510B 036 - TOWN OF STANTON
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 - O'FLANAGAN, CHRIS D & KELLY JO
CHRIS D & KELLY JO O'FLANAGAN
1580 CTY RD K
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1580 CTY RD K
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 25.520 Plat: N/A-NOT AVAILABLE
SEC 32 T31N R1 7W 25.52 AC SW SE EXC WEST Block/Condo Bldg:
478'
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
32-31N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1015/241 WD
07/23/1997 826/414
2006 SUMMARY Bill Fair Market Value: Assessed with:
166980 Use Value Assessment
Valuations: Last Changed: 05/06/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.520 15,000 152,400 167,400 NO
AGRICULTURAL G4 24.000 3,700 0 3,700 NO
Totals for 2006:
General Property 25.520 18,700 152,400 171,100
Woodland 0.000 0 0
Totals for 2005:
General Property 25.520 18,700 152,400 171,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 207
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 036-1082-50-000 01/11/2007 03:43 PM -
PAGE 1 OF 1
Alt. Parcel 32.31.17.510A 036 - TOWN OF STANTON
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 - FREY, DEBRA K
DEBRA K FREY
1556 CTY RD K
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ` 1556 CTY RD K
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 14.480 Plat: N/A-NOT AVAILABLE
SEC 32 T31 N R1 7W 14.48 AC W 478' OF SW Block/Condo Bldg:
SE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
32-31 N-1 7W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1186/512 QC
07/23/1997 838/94
2006 SUMMARY Bill Fair Market Value: Assessed with:
166979 Use Value Assessment
Valuations: Last Changed: 05/06/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.480 15,000 146,900 161,900 NO
AGRICULTURAL G4 13.000 1,500 0 1,500 NO
Totals for 2006:
General Property 14.480 16,500 146,900 163,400
Woodland 0.000 0 0
Totals for 2005:
General Property 14.480 16,500 146,900 163,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 207
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
n to 0 0 (n 0 g v 0 rte.
0 w f d f c 0 C r1
c c z 0 3
7 m 7 m (j (D C. e
(D CD c
-p I I az (D
/~fw
m 3 3 - ; C \1
3 - 3
a: Q
Cn 2 2 (n G) Z 2 u O n cn W° i .
W
0 W W (n O O O W (n N W N W Sr/1
O W
N O O O
Q d J n m a 00 - O .~.r
C CD W: 3 (D CO O - V A C ` )
N ro W W W W UI
n 3 C) co')
COD 0 CD (D 0 ro ° a
j_ m o_ n c o~ o
c 7 fA Cn 7 N (n ~ O
N N OD N N O \y
C O C
CI
ID *~~+1
S o n z 'r m a J
m a < G U a ro "C
p N C C O
c a
oV o Q o O G
J m
0 Z, (D O N N (~~►1
N (O z N O
C O CO
CD z N co 0 O O O O n r co
v
O
A ° ° Q g a
N
o v 3 T m v [r e
z 0 0 0 0 O O O°
0 * * * ° - iz * * *
O E -I -1 0 Z 3
CD
N N N(D
m ~ G o v m= ~ v o~ N
(Z3 N N UI .gyp N m N .Z7 90
n a - O n G
W - m W m -(D ? cr N
v 3 O
N ~ 3 J c 3 d o c
O m m O_ Q
z r ' \
G Z W 0 D m 0 U) z CTI
O D a _ O N
(a r-A
N om.
o m CD @
(D
-1 cn
ro w ) i^1
O N N e ~R
C (D (D C (D
N 0- O_
a 7 5-
m (6 IT (p --1 to
C' O O .P Z n
- i(n C O C ~
i A Z O
W a a
O
c W N
Oo T W
m m m m z
0 3 0 3 A
0 0 ' cn v
3 3 m
N (D O A
W N W N
O
N Z> 3 71 a - -O T,,> 3
? n m :-s: O
x Q m O -
A _ S ID a 2, 0
O T (n r
C~ T
O' W C 7 N W W G; C
O
a z a s a o z a
p O ? G
O (D
(ron
0, c N
m O m W
O W O O N
W (n m
m
3 CD
Ca-
o 0 m
m
N C (D W
~G- n~Q
r ~ocn
O W = m
O 7 m 00 J
O
p - W Q p
W W C V
O l O
(D (D )'efl O og a
O S O ~ "O O. 0 C7 v
Wisconsin Department of Heaith and Scoial Services
Flb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
IYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, city, zip coda)
B. LOCATION OF PROPERTY WARE SYSTEM WILL BE CONSTRUCTED. ALTERED OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
, TOWNSHIP
C. IS LOCAL PERIMIT REQUIRED FOR THIS WORK? YES NO % //PERMIT NUMBFR
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION ~ REPLACEMENT/_~ JADDITION
MATERIALS: Prefab Cor,orete Poired in Place Steel Other
NUMBER OF TANG TO BE INSTALLED:
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residem a Commercial industrial other
(Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer k YES NO
Dishimsher YES < NO Automatic Potato Peeler YES - NO
Other (Specify) _
G. MASTER PLUP13ER MAKING INSTALLATION
Name; Address, ' - License Numbert
Signature of Applicant: % i MP RSW y
J
Address:
H. (To be Compieted by Issuing Agent)
Uate of Application Fee Paid $
Permit Issued (date) Permit Number
Agent (Name) For:
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filinE until all of the above questions are answered and the
fee paid. Agents wi.l fore:ard application, the fee of $1.0~ for each septic tan;c and tine third cop;
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Heaith.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
T / (Initials) _ (Date) See,Corri y. )
FEE RECEIVED VALID. No. PERMIT N0.
Tec/ or No
REVIEWED BY APPROVED DATE
(Initials) (Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO.
R E P O R T O N S O I L P E R C O L A T I O N T E S T
A N D S O I L B O R I N G S i
TO
DIVISION OF HEALTH - PLUMBING SrrTI64
P.O.Box 309, Z°rAdison, Wis. 53701
Kt au ra to H 62.20, Wis. Administrative Code
P X R C 0 L A T I 0 N T E S T
Test Dept-h Character of Soil Hours Water Test Timo Drop in kater Level Inches utes
Number Inches Thieknoss in Inches Sinov Hole in Hale Interval Second to Next to Last To Fall
1st Vatted Ovorni t in Minutes Last Period Last Period Period One Inch
Example
P - 0 3611 To Soil 1019 Cls.. 26" 25 Yes or No 30 1 2 2 2 1 2 60
RECORD DATA FRO14 MINI111U]11 OF 3 TEST HOLES
Compute size of absorption area in accord with F 62.20 Wis. Administrative Coda.
S O I L B O R I N G S- Minimum 3611 Belo reposed Absorption System
Boring Total Depth De th to Ground Water Depth to Bodrock
Number Inches Cbserved Estimated Observed Estimated Character of Soil with Thiokness in Inches
Exestple
B - 0 I 7211 7219 Black To Soil 12" Clay 18"• Sand 18"; Gravel 2411
RECORD DATA FROM MINIMiUM OF 3 BORE HOLES
TYPE OF OCCUPANCYt
RESIDENCES Number of Bedrooms OTHER: (Specify) Number of Persons
FOOD WASTE GRINDERt Yes No X Dishwashers Yes No Automatic Clothes Flashers Yes ~ Na
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC&%IENT
Tile Size No.Lin.Feet / ^ ! Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter 6 7 Liquid Depth -Y
Is the undersigned, hereby eert'fy that the percolation tests reported in this fora were made by me or under rr 4uper-
vision in accord with the procedures and method speoified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME
TITLE
Type or Print)
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DAB i~ SIGNATURE' ( 1 ,
Z
V3 c/ - q 3
s~/sue- ~33.3~0
-3 X-~~f~ y
STANTON
T 31 N.-R. 1 7 W 5
65 y~~ 'vex/ Z Q/e POLK COUNTY
~lasr ,i/.~ e
y.v zo ~8 B- /-~~use~~ ~/'/vim /7 y,~a• h
~r sU,o% '6 a.ie~ L ~ may cLat'ob.ro/7 i. C CT ~ x
163 iss-89\ New zz6 v,C y d y / °`~s 7 'i'/- s y o [p f~
y EEE111 ~ zoir C e~ lv Ph,.,nd
L 9 ms - l n ~abcv/ bar/ ~V C
v r. _
Q ~ 40 ~ r6o i, n h Uha 4Mar @' L/e/er/ iPus,F 6'o C C~ ~/ooyQ ~ Q ~ ~ n
499en y -C3oche ~'y 4o Han fe`/ o 6t/ind~en .P chart! D vbczn ~i
ve ne-, . H B ~ ~iV r4a EKG i o 3~~ f'o u,Fcs
-.fe cf V~ f/owacd§
76 ^ pp n ,
T~^~t .Ci ~ e d° F/oc/v✓ QI /e `'n qri N m~ c o C :9 fe 7'
v_ QV h o v ° To ~141w~
oo ,lie~f.EP ~ ~60 s n l~u ,E3o ° ozw
7)
DI a \S /9
fa- ~CixO BO Bo/ ":bAKR~OG L. Mew ao3~s
°v .V7~ Le° -xd sr% r>c/ /I-- J /6a 2¢o Vaco6sorJ, 'L/~
. - Peed -
~ ~ l/a/Ferf 40 ' \ ~ I ~en.y /s7 of / C .C3>-os
/s9 /E ~ eyes . I~ .2-s 4 a
J n rE/in or-
Cii~so/fiame
c
M fa~~n,1 c- L n
76 \ ~ •
a✓ere • .9f F
Jmsch/e Conna %a ~Q 6es C v So ie
V01Ee,7- ~ ,Bet/rke Senn czar IJua..ne s
h /GB /%r>-,s ~iEo /60
Jacobson Cow ~ ~S'a6eai/ Q~~ E ~~o f~ an /zo ~a ys
Edwa d Lo ~On Cr - L¢o c cab q 160 yQ~ h`eiman 'fin°PP
V .~i-nsch,Fe /60 1V - LClns on /6a
y /oo /i W%6e./ ~ vu •Me~a~c~ Leo6
aC, cfimid~ ~a`~~ HoPklns Fian / m~9 ~ au/~ `O
owand /az.
q ~ ~ ~ v & N Janes es Y
~e~ha»s /E° Ba cTa /ir/~5-fog
o Bo z 6 0 4i
• h Cha>/es ® L S f
' L//ra i E ~3e Bo Beff~ Bo< o o R
~~z Ee Pa/ h *a zs ~1 E C x~o h o n ` ao
~s Mer/.7 4o Li ~W
E//e
P ~ M< o ~ ~ o C N ,Pahe~r ~r ~ ~ a„ Gera/d ti
//6 - Q!'~ ~Se7~6 /s6 3 ~7 3a r y ~ h ~ ~ ~ fitt.~ k ~s/e~s Casey
eff- C 7 /6a H/ei~~ac
/SL s
1Po/ctri~ i,Pf'a/znd V /la \~2 C 16o efux i 8
F/'if ~ {/C fins UPrrJC2~ Q ~ ~ D 41 ~ E~wa.d S -Z ao
/r6s V w o Cia /e /Eo /Pay en
117 C7 u, y cKczth. , j l/vic.Ee~ P frczid/~aso.~ O H Wsc
97 sfe c ~ Fa„k " hre
pfiens boaser- F/o d P n y ~ ~ zao ~e/6 ~~S
Bo ~C~,' r/-/1/`z>r~a.-a_ o Jofi . `l A a, a ~e~Y- yy
/y, /6 ns/oq LumPh~ y~ /6a Efc,Se
~Y e>-
.Cewc~ien~ -
o
~7g
/ ",I day ° E /zo cCJ v FQ %ken 4a L¢cv~eixe
65
ri y /zo h N 97 Bern. e9nn Q\ • Ba /60 ~7 Va no 4 Bale /
0
B/ 0 U/ ich ~ 'I. 0
e>na.~ FJm'rn SPA` W /Eo Chc.'s Tian v ~~Q'
f/atcfi Ivan f F~chand ~y w ~ ~ v) Loref~ ~ ~
o ~C3eafr>c~ c ~C ^ o p E/+ ene /.3efh,Ee o\~ V,
yy irc,E- o o. C ~Y. C cu VOIJ C .9 Jfin Al.
K"ode so.> E>vcks o» 4 v a h* o ,C v ~Jxe /7 o fl ,Ba 6 C' 136 ~tl\ o o, 'z
a7 /J 'b~ 1q x~ ~ ° iS e E I.p ~ C P ~ v /'t/h,fe
° d i a : h o J 1, Bo Bo l o ~'iu>n \ ~7///is • - \
316.47 ~ ,~s9 zo Nea/6cTea ~ f7/.ce ~
f 64 ,s K u
ae
U />s
v .9mos ~ • /09
y • 40
F
~ ancois f'ede,~sor~ ,
Tam a s
I' /~O /zo Were/ Bros, 79s
Wayne 5 Louise C'odc/ T ~a~/ an g Leo
NE H OND Fin es we/is ga
3sa ~7amcs a"dI-
~o~sseau
'IC ~ k q Be~nairL 1163 '471/'ss /60 0 .SensBi7
j P z¢O /~/'4n c/S co _
H ffa ve SE/o~erl o m .s
Z1 i ` s a ak y y 0 .um file / Mv/ s Cal f Phy//is ^1.s.
o Ribs- C'fii! f an 6'o12 Gao Pi6o /~a~fi~ Po we s B f
B ~ /60 ~ do M`Flo'cz>r~s GOOSE - /ya. ~t T/¢iser' ~ eke , /zo
° k Bo POND /ya fig J
liaise Taise~ j6o C/a e e f~a/fus o
SEE P GE 43 K izo /=a • 7g (~11` W~L O~
0197z ~ °E' ord MP ~6/s., 1 c. /za 40
SEE PAGE 4
cS7. C~oi r oc.a y Wis .
POLFUS IMPLEMENT INC. Now Richmond
CANNIN G Granite Works
CORPORATION PHONE: 246-2011
PHONE: 246-6565
MARKERS - MONUMENTS
NEW RICHMOND, WISCONSIN BRONZE TABLETS
54017 NEW RICHMOND, NEW RICHMOND, E
WISCONSIN 54017 WISCONSIN
AS BUILT SANITARY SYSTEM REPORT
't
OWNER TOWNSHIP f,~~/rp, ) SEC, ' LN-Rl7W
ADDRESS _j ST. CROIX COUNTY, WISCONSIN.
1
L.44U10 4"1117
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
hL_,E_V.EI~THING WITHIN 100 FEET OF SYSTEM
is
I di a e o th Arrow
SC LE: I i
BENCHMARK: (Permanent reference Point) Describe: 6di,14 dt9U4,~:'
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Manufacturer: % Liquid Capacity:
_
Number of rings on cover : Tank manhole cover eleVatiori-J
Tank Inlet Elevation: Tank Outlet Elevation: "
PUMP CHAMBER
Manufacturer: Number of gallons
(lumber of gal. pump set or a cycle. gallons; total capacity o
distribution lines gallon: size of pump head;
gallon per minute horsepower ran name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE: um er o pits feet diameter
feet liquid dept seepage pit in et pipe-elevation
bottom of seepage-Fit elevation _ feet.
SEEPAGE BED SIZE: number of lines width '1 length~tile depth,
SEEPAGE TRENCH: w dth, len th,
PERCOLATION RATE , AREA REW D AR A AS E BUILT
INSPECTOR
:DATED _ PLUMBER ON J B
LICENSE NUMBER 1 n
REPORT OF INSPECTION - INDIVIDUAL SLWA(A SySTLM
Saki4' ait if 1,citm"t -
s t SPptd'c ~
NAM1, Town~6ri_ fit. C!z"aA"x County
Locattions'-r~- see Secttan~~Lot # Subdkvi6ion
SEPTIC TANK
Size 1 gat2on,5 Nu_mbe,c oo eompantment6
Dti,5tanee f nom: We~f _ 6uiZdin9-- 12`0 6tope.
Htighwa te.tc
PUMPING CHAMBER
SIf2 ' -gae ~ an,, Pump Manu~aetune.~c Modek Numbe~c
HOLDING TANK
S'ze__ _ ga~ T'onb Nambc.lL o(I Compantment,5
Pumpers AE'atim Sy6tem
D-i,htav.cc from: Glee Bu..ti~dLvcg 120 ~~ope
gbrwaten
ABSORPTION SITE
Bed } Trtenc-6i
D~,dtane-e- ()}cam: (Ue"f~- 8ui di ng 12'6 Afape
Ili ghwaten
ABSORPTION SITE DIMENSIONS
Width a( the"n-eGco 1Zec~u'Aed anea---
l_engfor oo each ttine. yCJ_ ~t Depth oA cock be2aw tife_ ~n
Numbers oo Depth of noeh ovc~L ttiee ~ c n
~/-Fo of Iength of Y. kw'e 6t Depth of tilU betlow g,iade j n
L04'_5 tanee be twee "n k-i ne!~t S.Eape. a 6 tn.e.vi eh ~ vi . pe.n. 100 (x -
ii ~FotaQ ab~ onpt-tan a.nea--- It Type o(j Coven: Paper. oh. A Otaw
~f~tlT_DIMENSIONS / f
Numbeh of p-i.t% G~caveP an.( r. d n~t5 e5 no
Outside" diame.te~t" ~t Depth befow in f-ct {t i~
Totale ab3 otcp tion arse a ~t
A r x a
n e. q u~. tr e" ~ t
INSPECTED ) -fit.' Cpl E= TITLE-- - . ~~L - -
jO
APPROVED DATE'--- - 19 &
REJECTED DATE 19n
REASON FOR REJECTION
State and County State Permit #
PLB 67 ( County Permit #
Permit Application
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:
B. LOCATION: i , /4 /4, Section T.~_ N R (or) W Lot# City r
Subdivision Name, nearest road, lake or landmark Blk# y 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 %
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete - Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation RateTotal Absorb Area sq. ft.
New ReplacementAlternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenc s
Z' ri n i/ 1
Seepage Bed: _i_Length ~ > r -Width _Depth ~Tile depth (top) • xG No. of Lines
Seepage Pit: Inside diame er Liquid Depth No- of Seepage Pits
Percent slope of land ~ 2 Distance from critical slope
WATER SUPPLY: Private [0 Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
1, 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 Taster,
NAME ,-J, 4 , , 1, . -'j~l C.S.T. # ,S - and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# ^l .a 1, Phone #,i'
~4 e_ 9 "k Plumber's Address
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.
1, n w r m . m ...a a . _y,..e
1
F 4
3
t
3
a . ..e« s m a . R a - ...m. m ~ w ua ..ma ~M.. mu.Mm
i
E s
e
1
_ mod.. ..~~,..5.
t ~ t
F
s ' 3
a ' 3
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application,) ~--"--f y
Fees Paid: State unt D ~
Permit Issued/hrefesied• (date) r ~'-JZ -Issuing Agent Name
Inspection Yes No State Valid# Date Recd
1. county (whopy) 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
L - _
-DEPA,RZMENT OF_ - REPORT ON SOIL BORINGS AND SAFETY & BUiLDIN
INDUSTRY, , ~ DIVISIO
LABOA AN P.O. BOX 796
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53770
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
N/R i - (or) W
C TY: OWNER'S BUYER'S NA E: MAILING ADDRE .
USE DATES OBSERVATIONS MADE
NO. Reside nce BEDRMS.: 1COMMERCIAL DESCRIPTION: New Replace R FILE DESCRIPTION S: PERCOLATION TESTS:
❑
®
(jl RATING: S= Site suitable for system U= Site unsuitable for system
C: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTE Tonal)
❑S ❑U ❑S ❑U EIS ❑U [IS ❑U
ca
[under Percolation Tests are NOT re uired DESIGN RATE: SYSTEM EL
q If any portion of the lot is in the
s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: '~GQ
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLO EPTH
NUMBER ]DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK. L
> / r
r; s
B-
B-
6-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERT D PER INCH
h~
P- / 1
P-
P - ~
A& z IIX 4(1
P-
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. j
SYSTEM ELEVATION ('Z- 6
,
d
•
r fir- •
,
.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
mimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. _7
(print): TESTS WERE COMPLETED ON:
A &-A
CERTIFICATION NUMBER: PHONE NUMBER optional
CSTSIGNATURE:
ginal-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester.
r'
f
41 ~~C~ETSGkI i~ h s {
677Wton/ t
` r'T is
t:C
r 5
}Y -.ir ~ 1 r 1vt
10
I L, it L..~. ...N rlli4l f • *6, y 5_ rj
,
t2l
1
4
J; 1,
I`
a
Z
WT)
.1 .