HomeMy WebLinkAbout020-1116-60-000
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- ST. CROIX COUNTY
WISCONSIN
gill r~u~„; - ZONING OFFICE
r~r~f ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
March 11, 1994 VL~ ~ te q 71,
CTX Mortgage 26
7650 Currell Boulevard
Woodbury, Minnesota 55125 01
ATTN: Sheryl
Y
wT
RE: Septic Inspection for George and Joan Vesley
Address: 895 Willow Ridge, Hudson, WI
Dear Sheryl:
An inspection of the septic system on the property of George and
Joan Vesley located at 895 Willow Ridge, Hudson, Wisconsin, was
conducted today, March 11, 1994.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Should you have any questions, please contact this office.
S'ncerely,
Mary J. Jenkins
Assistant Zoning Administrator
mz
;L
7 ♦ 101-94
ST. CROIX COUNTY C~
WISCONSIN
ZONING OFFICE
rrxr■u■a - Mo..i
ST. CROIX COUNTY GOVERNMENT CENTER
' 1101 Carmichael Road
yL - - Hudson, WI 54016-7710
(715) 386-4680
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Please specify desired test(s) & remit appropriate fee with
application. Outside water lines are often turned off during
winter months, making access to the home necessary. Please make
irk arrangements with this office to insure that entry can be gained.
❑ Water (VOC's) $185.00 Septic $50.00
❑ Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria
retest $15.00
Owner: e-~Q V ej [am Requested by:1114
Address: W ~b Qc,s Address: 7(o-
ter ZIP 6` J b)") , ZIP r
Telephone 1`44: (71 L - Telephone NQ ( s) y ,
Property address (Fire NQ & Street)
Location: Sec. , T _N, R _W, own of wt.
Realty firm: Lock Box Combo: Clod ing Date:
' TO BE COMPLETED BY PROPERTY OWNER
PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Water sample tap location:
e.
Is the dwelling currently occup ed? ;N Yes ❑ No
If vacant, date last occupied:
Age of septic system: 7 c.~rS
Septic tank last pumped by:rjvq Qdp
Previous Owner's Name(s):}~
Have any o the following been observed?
❑Y Slow drainage from house. ❑Y PN Sewage Back-up into dwelling.
❑Y Sewage discharge to ground surface or road ditch.
❑Y [~N Foul odors.
Other comments relative to system operation:
I certify that the above information 's complete and true to the
best of my knowledge.
OWNERS SIGNATURE:
DATE:
1/94
OWNERS DRAWING OF USE & SEPTIC SYSTEM LOCATION
IN
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? []Yes ❑No sheet #
Soil series per SCS Soil Survey:
Type of soil absorption system: []Below grd ❑At-Grd []Mound
Approx. size 'X []Gravity []Dose []Pressurized
Ft.Z []Bed []Trench []Dry Well
[]Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank []Other
Setbacks: []House ❑Wel l ❑Prop . line v'
Dose tank
Setbacks: []House []Well ❑Prop. line []Other
[]Locking cover r pwarning label []Pump/Floats
[]Alarm []Elec. wiring
Soil Absorption System
Setbacks: []House []Well ❑Prop. line y; []Other
❑Ponding: []Discharge:
General comments
INSPECTORS SKETCH OF SYSTEM LOCATION
N
Y
Inspector'; L/1
Title 4
r
Parcel 020-1116-60-000 08/11/2006 12:45
PAGE 1 OF 1
F 1
Alt. Parcel 19.29.19.484 020 - TOWN OF HUDSON
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 - ERICKSON, BRENDA & QUINN
BRENDA & QUINN ERICKSON
776 103RD ST
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 895 WILLOW RIDGE RD
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 1.220 Plat: 2626-WILLOW RIDGE ADDITION
SEC 19 T29N R19W WILLOW RIDGE ADDITIION Block/Condo Bldg: LOT 9
LOT 9
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
19-29N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/15/2005 812106 2928/295 WD
04/06/1999 600757 1416/496 WD
07/23/1997 452/39
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.220 58,300 234,100 292,400 NO
Totals for 2006:
General Property 1.220 58,300 234,100 292,400
Woodland 0.000 0 0
Totals for 2005:
General Property 1.220 58,300 234,100 292,400
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
AS BUILT SANITARY SYSTEM REPORT
)*r EP. e Is c , TO~IIISHIP-~~ ~ SF,' . T L Iv', 1t~W
0. ADDRESS ST. CROIX COUNTY, WISCONSIN.
t..- _
,!DIVISION li p ~C, ~i LOTA~ LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
JT,
! j i f
--1---
i
i I r A i
_ 1~ I 1 I j
- --------j-- _ 1--F - - 1 - '
V_ 7-1
i Indicate North Arrow i
SCALE : - - -
-PTIC TANK (S) 100() MFGR. (j Q p S CONCRETE STEEL
NO. of rings on cover I Depth DRY WELL
1ENCHES NO. of width length area
no. of lines width length area
depth to top of dipe
, ?:ELATE ~ (2_ oct,
t': RATE AREA REQUIRED AREA AS BUILT
,yciaimer: The inspection of this system by St. Croix County does not imply complete
orpliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
stem operation. However, if failure is noted the County will make every effort to
etermine cause of failure.
c-ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST
~INSPECTO
" _ (Ltd
DATED PLUMBER ON JOB
LICENSE NUMBER
• AS BUILT SANITARY SYSTEM REPORT
'XiER~ , TOWNSHIP SEC. T N, R W
ADDRESS , ST. CROIX CGUNTY, WISCONSIN.
BDIVISION LOT LOT SIZE- .
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
P1
IF-
+
I I I i- j I----
~ I ' I + r ~ I + I + I i I
! = - - i._-~-- I t
r t-- Indicate North( Arrow
!S CALF . - +
I i
'„V'TIC TANK(S) MFGR. CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
►I:,NCHES NO. of _ width length area
no. of lines width length area
depth to top of pipe
0S EGATE
`Q!K RATE AREA REQUIRED AREA AS BUILT
s,Qiaimer: The inspection of this system by St. Croix County does not imply complete
oi,pliance.with State Administrative Codes. There are other areas that it is not possible
0 inspect at this point of construction. St. Croix County assumes no liability for
Stem operation. However, if failure is noted the County will make every effort to
J. 'ne cause of failure.
CEASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
'-INSPECTOR
DATED PLU:fBER ON JOB
LICENSE NUMBER
REPORT OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM k
SanitaAy Pv m.i-t
State Septic
NAME i own.ah.ip ST. CAo i.x County
Location Section
SEPTIC TANK
Size gatton~s. Number o6 Compatetmentz j
D-vstanee FAlom: Wett St. 12% ok gtceateA Atope 6t
Bu.itd.ing 6t. Wettandz 6t.
H.ighwate& 6t.
DISPOSAL SYSTEM
D.ietanee Fkom: Wett St. 120 o& gAeatvL 6tope 6t.
Bu.itd.ing__ 6t. Wettands Ft.
HighwateAC 6't.
FIELD DIMENSIONS:
W id•th o6 tAlench 6t. Depth o4 tco c b etow tite in.
Length o6 each tine St. Depth o6 tock ovetL t.ite in.
Numbek o6 tineA _ Depth o4 tiZe below gtLade in.
Totat .length o% tine6 4t. Stope o4 tALeneh -in pets 100 Zt.
Distance between ?-ines 4t. Depth to be.dtLock gt.
Total ab.60tLbtion area gt2 Depth to g~LoundwatetL ti.
RequiiLed a,Lea $t2 Type of CovvL: Paper on SttLaw
PIT DIMENSIONS:
NumbvL ob pigs Gkavet atcound p.itz yes no
Outts.ide dt.ameteAL_ 6t. Depth below ,inlet 6t.
Total absonbt-ion atcea 6t2. z
A
AALea ALequk;ALed 4t2 rn
INSPECTED By TITLE
APPROVED DATE 197.
REJECTED DATE 197
t
R
1
67 State and County State Permit #
PCB
Permit Application County Permit # 4
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: /4, Section 1g, T2XN, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# r Village
/,pj Township t /
C TYPE OF OCCUPANCY *Commercial *Industrial Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons--57
D. SEPTIC TANK CAPACITY trC--C Total gallons No. of tanks :L ~
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete--2~_ 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 Rate-
Total, Absorb Area sq q. ft
ft"
New Replacement Alternate (Specify) A hh a'T" r Q f,;
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth_ Tile depth (top) No. of Lines
Seepage Pit: Inside diameter---Z • Liquid Depth L
No. of Seepage Pits
Percent slope of land- Ze ~e frt , Distance from critical slope_
WATER SUPPLY: Private L Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
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 Cert fled Soil Tester,
NAME -T- _C.S.T. # S -C Z land other information
obtained from q_ ( C C ~C--~ L/ (owner/builder),
Plumber's Signature MP/MPRSW# Z'6 I!Z Phone
7, Z-
Plumber's Address f C t /CJ j c 7 r U C` f
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.
r r -
VT A ~ i
s t E
d
3
3
3
-
E
100
Do Not Write in Space.. Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application ' Fees Paid: State County,, Dale
i
Permit Issued/Rej=ted (date) Issuing Agent Name G. {
Inspection Yes _No State Valid#
1. county (white copy) 3. owner Date Recd
(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
&eturn Receipt Requested j
DATE: January 26, 1979
4Ir. George Vesley
Route 2 ~ LOCATION: Willow Ridge I
Willow Ridge
Hudson, Wisconsin 54016 Township of Hudson
Dear Mr. Vesley
As required under the ST. CROIX COUNTY ZONING ORDINANCE, notice is
iereby given that you are in violation of Article 6.3A of the
he ST. CROIX COUNTY ZONING ORDINANCE.
The violations noted are drainage of existing sanitary system
ver the surface of the ground down into a dryrun. (watercourse)
a
nd the following actions should be taken by immediately.
he drainage must be stopped immediately and a licensed pumper contacted
o remove the effluent. The failing system shall be corrected by
ontacting a licensed plumber. This correction shall be completed
y April 15, 1979. .
The first violation is noted as having occurred 1/25/79 ,
nd any penalties provided for in the ST. CROIX COUNTY ZONING ORDINANCE
hall be applicable as of that date.
Please feel free'to contact this office, for we are available to
3sist you in clarifying this matter.
Yo}drs truly,
j
HAROLD C. BARBER
Zoning Administrator
;B: jh
Town Clerk
District Attorney
EH 115 Rev. 9/78 ~14~~/ / `j
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
F /
LOCATION: G / Section ° I ,T_LyN,R /E (or) W, Township or Municipality V/ A
Lot No. _Block No:/~~~D_ Countyf- `~lX
Owner's/Buyers Name: Subdivision Name
41
Mailing Address:_ GV%~~(J~~ t~0 y~~ A
TYPE OF OCCUPANCY: Residence--X-No. of Bedrooms - C RC44L
Te0A rev f •~>~ec1 v y tz~~r/,
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ®yiALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE- SOIL BORINGS _ O _'2 Z PERCOLATION TESTS_ 7
SOIL MAP SHEET NAVE OF SOIL MAP UNIT _5277AK S';Z~T L
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
NUM- JDEPTH CHARACTER OF SOIL
SINCE HOLE HOLE AFTE INTERVAL RATE
BER INCHES THICKNESS IN INCHES MIl`!/IN
~r 1STW{ETTED SWELLING IN MINUTES PERIOD 7 PERIOD 2 PERIOD 3
fZ/ 6 /
P_ 41 Ars, &I I;lj
P_ re.2
P-
-Of /411y
P- /;V
1P_
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
//O//BSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 6) id. aw 6~E 0 ` . 1.,l . - 77174-
/ a~ -
" e
B ' 2- 7 / 01 SV ii
B-
B-
B-
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy U - Fo,f Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
1
e
Pay
= ~'%~PC aod' xl 1, ,,r
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14
a~ I, 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.
/
Name (print) Certification No.
Address FT
Name of installer if known EXPA4 /COS • E 2'ff ,~fT 1y,6--
Copy A -Local Authority CST Signature_ e i_
r
E1 1 115 Rev. 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 T_N,R_E (or) W, Township or Municipality -
Lot No. , Block No. it) County ~f e-AOIX
Subdivision Tame
Owner's/Buyers Name: &/f, VIES C.e f
Mailing Address:
Ekr_ /Xer / sue? 7;41 TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET NAME OF SOIL MAP UNIT -
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTER INTERVAL
INCHES THICKNESS IN I NCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
BER
P- 2- N 4r 12-1 N
P _,!rCy/4 /;Q
P_ r
P_ G, I
-7'Q <
P_ / ot1. ~E %(1
P- F_ ER TT p ' fi JOE oec.'
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
04
B- A,,11 37Y
B- l
B-
B-
B-
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on th/eel/plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy Sal 4t3Indicate scale or distances.
l
Give horizontal and vertical reference points. Indicate slope.
t ~ E
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a
I, 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.
"10 Certitication No.
Name (print)
Address A9lene~Q~,
Name of installer if known-Z4- lee)-~-
Co A -Local Authority CST Signature
PY
EH 115Rev. 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 ,T_N,R_E (or) W, Township or Municipality
Lot No. Block No. 1~' t4) jp~~ County -
Subdivision Name
Owner's/Buyers Name: _
Mailing Address:,
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL -
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET NAME OF SOIL MAP UNIT - r
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RA-r
DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTE INTERVAL
MIS'
NUM INCHES THICKNESS IN INCHES PERIOD 1 PERIOD 2 PERIOD 3
BER 1ST WETTED SWELLING IN MINUTES
PP _ AF Y2_
P- Q
P-
P_
SOIL BORING TESTS
CHARACTER OF SOIL WITH THICKNESS, COLOR, _ l
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B-3 MI'Ve ;1 6 Z. -811, 5~11, .16
B-
B-
B-
B-
B
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy' _I-rloloc ,Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. /
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46
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~FRC /t _~/ZOM IZi' CE MI 1~DI ~ i TO
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P a of Vii? wEl)
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I, 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.
Name (print)' Certification No.
Address Z
Name of installer if known
Copy A -Local Authority CST Signature
Wisconsin Department of Health and Social Services
I'~b• #67 3/70 Division of Health
,'y 2 2-
SEPTIC TANK PERMIT APPLICATION OTS l _
bald l9(~~(
TYPE or USE BLACK INK A. OWNER OF PROPERTY) o%(G N S C ll(
Name Address (Street, City, Zip Code)
F
--WZ/,O.
B. LOCATION OF PROPERTY W-mRE SYSTEM WILL BE CONSTRUCTED ALTEREr OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? ~ YES NO v PERMIT NUMBER
D. SEPTIC TANK CAPACITY D®O Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poued in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED: _ J
E. TYPE OF OCCUPANCY
Check One= One or Two Family Residence Commercial Industrial Other
Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO
Dishwasher_ YES NO Automatio potato peeler YES_,::~- NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION c
Name: -4 0 ~G9v=tiitj j ~ Address: Ll IS-/ License Number:
Signature of Applicant: MP RSW
Address: L~~ s'I✓f) „ /
f-
H. (To be Completed by Issuin3 Agent)
Date of Application 170 Fee Paid
Permit Issued (date) O Permit Number zy.Z7
Agent (Name) ~6tl)- For ~L
Tow.i, Village, City, County, etc.
(Specify)
Note: The application cannot La ,.,nsidered for filing until all of the above questions are answered and the '
fee paid. Agents will forAard application, the fee of 31.00 for each sepcio taruc and the third copy
of the permit (canary) :o the Division cf Health. Checks and e.oney orders should be made payable to
the Division of Hesith.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED I ~/"7 Q ACCEPTED BY RETURNED
(Initials) (Date) RECEIVED ✓ VALID. No. 3 Sea Cdr-e G.}
_ l }
(Yes or No) PERMIT NO.
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTTER SIDE
SEPTIC TANK PER,-ii, uo.
R L P 0 R T, O N S O I L P I R C 0 L A T 1 0 N T E S T
' A N D S O I L B O R I N G S
' TO
DIVISION OF HEALTH - PLUMBING SECT16A
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P S R C 0 L A T I 0 N T E S T
Test Depth Charaoter of Soil Hours Water Test TLae Drop in Water Level Inches as
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last rT~ou!ll
lst Wetted Overnight in Minutes Last Period Last Period eriod : Inch
Example
P - 0 3611 To Soil 10" Clay 2611 25 Yes or No 30 1/2 1/2 1/2 60
„ >12
'j 0
RECORD DATA FROM MIND`SUM OF + TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Minimum 3611 Below Pro osed Absorption S stem
Boring Total Depth Depth to Ground Stater Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thioknes in Inches
Example
B - 0 72" 72" Elaok To Soil 12'* C1 18l' Sand 1814 Gravel 2411
`12- k 2 Cc 2 . 2G { +L
RECORD DATA FROM MINL`UM OF " BORE HOLES
YPE OF OCCUPANCY: 7
RESIDENCE: Number of Bedrooms OTHER: (Specify) Number of Persons D WASTE GRINDERs Yes No Dishwashers Yes No Automatic Clothes Washer: Yes No
FFWENT DIS?OSAL SYSPEMp NEW EXTENSION ADDITION REPLACEIENT
Tile Size / No.Lin.Feet Trench Width Depth Number of Lines
i
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pit: Inside Diameter Liquid Depth
2, the undersigned, hereby certify that the percolation tests reported ci this form were made by me or under ray super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisoonsin Administrative Code, and
that the data recorded and location of test holes are correct to the best Hof my knowledge and belief.
NAME TITLE ~V7-n-_1 11,
Type or Print /
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS /L 1*
DATE /-Z h D~/~D SIGNATU-Pi
9 7
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I/ y (0 2/Z ~o ~u y,s !ft 7o lrf s _
LoT-Gl ~S2/3~i r W7
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