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HomeMy WebLinkAbout020-1135-70-000 V ' n CO) p E -0 n rw C 03 ° r/1 .d. 7 Co 3 W n A -p A7 CD c 0 3 3 A- O 31 :E Z N) C:) CD_ ((D N O 7 Z CL O l^\ C 3 O W = O N d j O N N m y ~S 0 CD C j J O O 0, CD cn 3 0 I CD l►1 N ~ C) O N_ N ~y DI c U> C D ~ a c m n m W a ( CD (D C n O O w 3 4 -;l (n lot i~~ In C O 0) C CD co n fB CCD CDD ~ on N "O r s G z O O O cn !i ° cn r-3 w c a a can m 00 3 ~ M co = -CD ~ n N S O CD N N n N z ~ y z co z n O CL 7 v O D CD O N O cI ~ C O N ~f C (D N CD w n n 3 7 Z (D -i Ul O p Z CD N CL A 7 O. ~ C W CD ICI, < (ND O CD CD 0 3 a 0 z 0 z CD w ~ a a N n v T v c o z CL O m ~ m 3 0 o o zi A I i a II I ti 0 0 a A O C=D A N E» O yH CD Ca. ~ Parcel 020-1135-70-000 08/14/2006 05:05 PM PAGE 1 OF 1 Alt. Parcel 20.29.19.667 020 - 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 ADAM C & ELIZABETH J SMITH O - SMITH, ADAM C & ELIZABETH J 951 RIDGE PASS HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 951 RIDGE PASS SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 1.540 Plat: 2624-WILLOW RIDGE 2ND ADD SEC 20 T29N R19W WILLOW RIDGE 2ND ADD Block/Condo Bldg: LOT 58 LOT 58 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1070/625 WD 07/23/1997 957/415 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/30/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.540 66,000 200,200 266,200 NO 05 Totals for 2006: General Property 1.540 66,000 200,200 266,200 Woodland 0.000 0 0 Totals for 2005: General Property 1.540 66,000 161,200 227,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT TOWNSHIP SEC T t_ , T c v" r. AD RESS, ST. CROIX COUNTY, WISCONSIN. 3DIVISION LOT LOT SIZE j_ Y,' PLAN vlEw 020 I/3S- 70- Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM eV Al 0)~ ..TIC TANK(S) . MFGR. CONCRET,E Z _ STEEL NO. of rings on cover Depth ,,.DRY WELL NCHES NO. of width length area no. of lines_'~ width i_ length area d ptih to top of pipe ZEGATE RATE AREA REQUIRED _ -AREA AS BUILT aimer: The inspection of this syste by St. Croix County does not imply complete fiance with State Administrative Codes. There are other areas that it is not possible--,-,' pect at this point of construction. St. Croix County assumes no liability for ' operation. However, if failure is noted the County will make every effort to 'ne cause of failure. AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. "INSPECTOR DATED ? 9 ~ PLUMBER ON JOB ..r, LICENSE NUMBER ST. CROIX COUNTY WISCONSIN A r en0q n ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 February 23, 1994 Ms. Kathy Smith //3S Edina Realty 700 Second Street } -2 Hudson, Wisconsin 54016j~l RE: Water and septic Inspection for Jeff Borgstrom Address: 951 Ridge Pass, Hudson, WI Dear Ms. Smith: An inspection of the septic system on the property of Jeff Borgstrom located at 951 Ridge Pass, Hudson, Wisconsin, was conducted on February 14, 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. Also at the same time, a water sample was taken. Enclosed is the original test results from Commercial Testing Laboratory, Inc. for water inspection of the above property. If you have any questions with regard to said report, please do not hesitate in contacting our office. Sincerely, /s/ Mary J. Jenkins Mary J. Jenkins Assistant Zoning Administrator mz Enclosure 4__ MF COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 Cj:: FAX -715-962-4C3C .:1,KOIX G'11 GUV.CTR REPORT MATEY 2>1 ,J1 CARMICHACL ROAD - x. ^(~t t y ,,!T ~1ATIONY 951 Rid,, LECTORS M. ,lent:. E COLLECTED'* 2-14 1E COLLECTEW 3S3i KE OF SAWLEY I-. tchen f ucet ANALYZED4i e,... ,NALYZEB Y 2' OQ!- !hM, `9FCC S 0 °3kPRETATION*# Bacter 4 pp.. cs- LAB TECHNICIANS Pam Gafte OF.\NDEPFNOENT. r/~e p T Approved Lab No. 14 0 A t+ 01 3t bD PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 SEPTIC INSPECTION WATER TEST REQUEST FORM / •,1i~Specify desired test(s) & remit appropriate fee with application. 1( Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. 0 Water (VOC's) $185.00 VSeptic $2a.;=0 0 Water (Nitrate & Bacteria) $35:-!36 (Visual inspection) i ~ Owner: c;(( `&(c" Requested by: k G,, {uiy ,mot -off Address Address: City & State: City & St._ linc4c,"l,~ Zip Code: Zip Code: Telephone N°: (J)>`. - j 5 i Telephone N4: Property address (Fire N4 & Street) : Location: k k, k' i , Sec., , T N' R1` Town of . St. Croix Co., WI. Tax ID N4 Parcel ID N4 House color: ~)(L,,C Realty firm: Lock Box Combo: Water sample tap location: TO BE COMPLETED BY PROPEkTY OWNER PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS Is the dwelling currently occupied? 'B~Yes 0 No If vacant, date last occupied: Septic system installed by: Year: q 7 q Septic tank last serviced by: Date: ac i' Previous Owner's Name(s) : L,; and Have any of the following been observed? ❑Y 414, Slow drainage from house. ❑Y N Sewage Back-up into dwelling. ❑YN Sewage discharge to ground surface, 7 road ditch or body of water. 2 ❑Y 90 Slow drainage from the dwelling. ❑Y XN Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. t/ OWNERS SIGNATURE: sell- DATE : ~ y 4/93 OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? []Yes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd OAt-Grd ❑Mound Approx. size 'X ❑Gravity []Dose ❑Pressurized Ft.2 ❑Bed OTrench ODry Well ❑Holding Tank ❑Outfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: OHouse_ OWell ❑Prop. line ❑Other _ Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover OWarning label OPump/Floats ❑Alarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House []Well OProp. line []Other ❑Ponding: ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title i Cot"MERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.' 24492/01 PAGE i ST. CROIX COUNTY REPORT DATE) 6/22/92 COURTHOUSE DATE RECEIVED: 6/18/92 HUDSON, WI 54016 ATTNS THOMAS C. NELSON z OWNERS Paul 6 Jacqueline Tuckner LOCATIONS 951 Ridge Pass, Hudson COLLECTORS M. Jenkins DATE COLLECTED: 6-17-92 TIME COLLECTED: 2:00pm SOURCE OF SAMPLES Kitchen faucet DATE ANALYZEDS6-18-92 TIME ANALYZEDS2S00pm COLIFORMS 0 /100 ml INTERPRETATIONS Bacteriologically SAFE NITRATE-NS 2 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECHNICIANS Pam Gane OF.NDE CE,ypE~ c 'e WI Approved Lab No. 19 O p v > J < Means "LESS THAN" Detectable Level Approved by: PROFESSIONAL LABORATORY SERVICES SINCE 1952 1 ST. CROIX COUNTY ZONING OFFICE -14 St. Croix County Courthouse 911 4th Street iCqA Hudson, WI 54016 Telephone - (715)386-4680 W The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion at this form ia essential aQ that = property can Dg located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING----------------------------FEE: $ 35.00 (For nitrates and coliform bacteria) WATER TESTING FEE: $185.00 (For VOC'S) SEPTIC SYSTEM INSPECTION FEE:_ $25.00 (Determines if system is properly functioning at .,time of inspection) PROPERTY OWNER IS NAMEI r PROP. ADDRESS : _ c)5~_ ~ ;(A (,,S CITY c ~ r~- Legal Description 1/4 of the 1/4 of Section T_jN-R_LL Town of Lot Number T 7T-Subdivision: FIRE NUMBER LOCK BOA} U1M$ER - Color of house_5 --,e Realty sign by house? L If so, list firm: f' r-I PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP(J.e'COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: _ Telephone Number 3"-, -'1 ~ REPORT TO BE SENT TO: c kx; °L LOSING DATE. 1, in Si.gna ure- rYl c~ i _ C . C Jcs' ~~c~Sa 0,6 r ST. CROIX COUNTY WISCONSIN r'; ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 June 17, 1992 Jeff Borgstrom 6406 Bergstrom Rd. Sagenaw, MN 55779 Dear Mr. Borgstrom: At you request, I returned to the paul and Jacqueline Tuckner property, located at 951 Ridge Pass, Town of Hudson, St. Croix County, Wisconsin, to obtain the following distances: Septic tank to well 64 feet; Drainfield to well --110 feet. code requires a distance of 25 feet from the tank to well and 50 feet from the drainfield to well. Should you have any further questions, please contact this office. Sincerely, Ilk MarV..-J. 0~6enkins Assistant Zoning Administrator cj cc: Paul Tuckner SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636.7178 LABORATORY ANALYSIS REPORT NO: 21564 PAGE 1 05/28/92 St. Croix County Zoning DATE COLLECTED: 05/13/92 911 4th Street DATE RECEIVED: 05/14/92 Hudson, WI 54016 COLLECTED BY : CLIENT DELIVERED BY : CLIENT SAMPLE TYPE WELL WATER Attn: Mary J. Jenkins SERCO SAMPLE NO: 40752 SAMPLE DESCRIPTION: Tuckner ANALYSIS: Bromodichloromethane, ug/L <10.2 Bromoform, ug/L <0.5 Bromomethane, ug/L (Methyl bromide) <1.0 Carbon tetrachloride, ug/L <0.2 Chlorobenzene, ug/L 41.0 Chloroethane, ug/L (Ethyl chloride) <0.4 2-Chloroethylvinyl ether, ug/L <0.4 Chloroform, ug/L 0.6 A Chloromethane, ug/L (Methyl chloride) <0.6 Dibromochloromethane, ug/L <0.4 (Chlorodibromomethane) 1,2-Dichlorobenzene, ug/L <1.0 (o-Dichlorobenzene) 1,3-Dichlorobenzene, ug/L <1.0 (m-Dichlorobenzene) 1,4-Dichlorobenzene, ug/L -<1.0 (p-Dichlorobenzene) Dichlorodifluoromethane, ug/L (Freon 12) <0.5 1,1-Dichloroethane, ug/L <0.1 1 , 2-Di chl oroethane, ug/ L <0.2 (Ethylene dichloride) 1,1-Dichloroethene, ug/L <0.2 c trans-1, 2-Di chl oroethene, ug/L <10. 1 1 , 2-Di chl oropropane, ug/L <0. 1 cis-1,3-DichloroPro ene u /L P ~ 9 41.5 !c t trans-1,3-Dichloropropene, ug/L <0.9 j ~ t < means "not detected at this level'". 1 mg = 1000 ug. ! Member SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 21564 RAGE 2- 05/28/92 SERCO SAMPLE NO: 4075 SAMPLE DESCRIPTION: Tuckner ANALYSIS: Methylene chloride, ug/L <5.0 (Dichloromethane) 1,1,2,2-Tetrachloroethane, ug/L <0.2 Tetrachloroethene, ug/L <1.5 1,1,1-Trichloroethane, ug/L <5.0 1,1,2-Trichloroethane, ug/L <0.1 Trichlorofluoromethane, ug/L (Freon 11) <0.7 Vinyl chloride, ug/L <1,0 Benzene, ug/L <1.0 Ethylbenzene, ug/L <1.0 Toluene, ug/L <1,0 Trichloroethene, ug/L <0,4 This sample - s analytical results are ~ar-e-Tn5t , below the U. S. EPA - s SDWA Maximum Contaminant level of 1/30/91 for those requested compounds which are also on the SDWA MC:L list, A: This parameter observed in lab blank at a concentration of 0.5 ug/L f means "not detected at this level". 1 mg = 1000 ug. Member Ar.~ - SERCO Laboratories 1931 West County Road C2. St. Paul. Minnesota 55113 Phone (612) 636-7173 FAX (612) 636-7178 LABORATORY ANALYSIS REPORT NO: 1564 PAVE 3- 05/28/92 All analyses were performed using EPA or other accepted methodologies. Samples that may be of an environmentally hazardous nature will be returned to you. Other samples will be stored for 30 days from the date of this report, then disposed of by SERCO Laboratories. Please contact me if other arrangements are needed. This report may not be reproduced, except in its entirety, without prior written approval from SERCO Laboratories. Report submitted by, Diane J. nderson Project Manager i < means "not detected at this level". 1 mg = 1000 ug. Member FFFFFFFF A X X F A A X X F A A X X F A A XX FFFF A A XX F A AAA A X X F A A X X F A A X X oa ~~i ST. CROIX COUNTY COURTHOUSE 911 Fou4th S.tnee.t Hudaon,Wl 54016 DATE: TO: FAX NUMBER-- c 1 3 NAME: c, r FROM: FAX NUMBER: (715)386-4628 NAME: (7 j Q~,~ &I. NUMBER OF PAGES INCLUDING COVER SHEET: IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: a, 1?, TELEPHONE NUMBER: _3Cc' ~~(o~~A 0 0 FFFFFFFF A X X F A A X X F A A X X F A A XX FFFF A AAA A XX F A A X X F A A X X F A A X X 6L ST. CROIX COUNTY COURTHOUSE 911 Foukth Stnee.t Hudaon,Wl 54016 III DATE: TO: FAX NUMBER: NAME:` w FROM: FAX NUMBER: (715)386-4628 NAME: L6 I(" NUMBER OF PAGES INCLUDING COVER SHEET: IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: TELEPHONE NUMBER: O o O ~ a a~ i COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 4:i:w T. CROIX ZONING DEPORT N0.! 22579/01 PAGE 1 ST. CROIX COUNTY REPORT DATE! 5/18/92 COURTHOUSE DATE RECEIVED! 5/14/92 HUDSON, WI 54416 ATTN! THOMAS C. NELSON OWNER! Paul 6 Jacqueline Tuckner - LOCATION! 951 Ridge Pass. Hudson COLLECTOR! M.Jenkins DATE COLLECTED: 5--13-92 TIME COLLECTED! 3l00pm SOURCE OF SAMPLES Kitchen faucet DATE ANALYZEDIS-14-92 TIME ANALYZED:2140Opm COLIFORM! 0 /100 m( INTERPRETATION! BacteriologicaLly SAFE NITRATE-N! 4 ppm Above 10 ppm exceeds the recommended PuhLic Drinking Water Standard. Coliform Bacteria/100 mL Nitrate-Nitrogen, mg/L LAB TECHNICIAN'# Pam Gane 04AgDEPENDFHl WI Approved Lab No. 19 O P u > J < Means "LESS THAN" Detectable Level Approved by! o PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential aQ that $hg property can bg located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. t/ WATER TESTING----------------------------FEE: $ 35.00 (For nitrates and coliform bacteria) WATER TESTING FEE: $185.00 (For VOC'S) C/ SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 (Determines if system is properly functioning at.time of inspection) PROPERTY OWNER'S NAME : k, r k.;.. PROP. ADDRESS:- i CITY Legal Description 1/4 of the 1/4 of Section T N-R Town of 14,- Lot Number Subdivision. FIRE NUMBER I LOCK BOX NUMBER Color of house;- Realty sign by house?,,, If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A HAP,i.e,COPY OF PLAT BOOR, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Telephone Number REPORT TO BE SENT TO: CLOSING DATE: Signature %~~"c~~!:~~:~a. J i~ } -;n~~~~ On F~ Cn~ nCgK 9 ~d ~~~c~~'c> ~u~.-~ tc~~~~~„~ ~~~~ck~_ pd~r~~cGZ; ST. CROIX COUNTY r 4 l 5r}V WISCONSIN ZONING OFFICE r`v5 F ST. CROIX COUNTY COURTHOUSE TTT 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 May 14, 1992 Paul Tuckner 951 Ridge Pass , Hudson, WI 54016 Dear Mr. Tuckner: An inspection of the septic system on the property of Paul Tuckner, located at 951 Ridge Pass, Hudson, WI was conducted on May 13, 1992. At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. 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. sincerely, ~ Mari -J . 1Jenkins Assistant Zoning Administrator cj C 1. CY f i lqlliA 6d714.gt~dLL G 71 c /t c • Z ' REPORT OF INSPECTION-INDIVIDUAL SELVAGE SYSTEM San.ita}zip Pe-`c nit Septic State NAME (own.6 hip St. Cno.ix County I Location Section SEPTIC TANK Size gaZton6. Numbers o4 Compartments Diztanee Fnom: weZZ it. 120 on greaten 4Yope it it. WetiY-andh ~ • Building Highwate DISPOSAL SYSTEM D.ibtanee Fhom: WeZZ 6t. 12% on greaten 4Zope_ it. Bu.i.Ld-ing it. WetZands Ft. H.ighwa.ten it. FIELD DIMENSIONS: Width o6 drench it. Depth o6 no ck b eZow tiZe in. Length o6 each Zine it. Depth o6 rock oven tiZe in. Numbers o6 Zine.5~ _ Depth o4 tiZe betow pade_ in. TotaZ Zeng,th o6 tinee4 it. Slope of trench in pv, 100 it. D.i,6tanee between Una it. Depth to bedrock Totaf- ab,6mbtion vLea_ ~t2 Depth to gtLoundwaten 2 ek on Sttaw r St Type o Coven: Pa p RequiLed aea PIT DIMENSIONS: Number o6 pit4 G)Lavet a,cound pith yea no Outside d.iameten it. Depth below inlet it. 2 Total. abz mbt.ion area it A Area nequined 6t2 m INSPECTED BY TITLE APPROVED DATE 197. REJECTED DATE 197. A EM-115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPOR~JT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: • ~'/4, x" /4, Section ? T?/ N, R L1 E (or) W, Township or Municipality s LotNo. BlockNo. tu111©u) RI0G County 5T- C`Ro~. ' PA V L TU C-K~E R Subdivision Name l Owner's Name: /1 Mailing Address: 77 CoUtEE~ I~ p® HUP5o1,,J 5, C✓-10~ G T.. TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION g REPLACEMENT -7 DATES OBSERVATIONS MADE: SOIL BORINGS ,7/ PERCOLATION TESTS SOILMAPSHEET 56 57 SOIL TYPE e PERCOLATION TESTS T~,V 3 TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHAR NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 XMV, 51 CF /,0 Q-,6W 1A` 644A P_ j 3& ~r, AQ4 iaED tic ES " ~~/~E / ss P- z 341 3 5L, 33 " C 5 4u;g 51- 0 -/A eut- ~TFS. P- 3 7r p 3 C®.c~~ rah%U /~~t iaCJ<-- SOIL BORING TESTS i C TE'- a/~ ESQ' TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) L OIl9C 77-1 SL A G 5,4,uD S G /P . B 3 72, -7 2 sad. I-e M _32 " G. . 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. !9B' fo& 46rvc4 w/j- ~ E1J Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. (31 H 11% 60 1 I 0 d E, I ! I is ; Pro 00S It, T, IF ! 51QP - + T t - I fi + I f 5 c~ I If i f 1V/ fl -`i ~ f~ ry I I - T E 1 AIRE 't; - 13 P, + ~1 L7 1 + a { s ijc - ✓YY, r ~ C ~ rte' _ 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 location of test holes are correct to the best of my knowledge and belief. Name (print) e©b t g . ~ ( b R 1 C k7 Certification No. O Address RT. I H UF,).S 0 rJ S L/0/ (o Name of installer if known CST Signature Mqff COPY A-- LOCAL AUTHORITY PLBState -67 and County State Permit ph4 # Permit Application County Per , for Private Domestic Sewage Systems County 1 *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: '/4 '/4, Section T_ N, R_ E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# 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 Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) i 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 Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private 0 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 Certified Soil Tester, NAME C.S.T. # and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW# Phone # 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. i d ~ r i r 4 4{-- t r { ~ ,m. T R . t J s. +mt „...m, em ~,ao .a P ...e 1\!.C. s.. m.-~'" 3 e ZZ, A, , J' , 3 j E ` t_ 91 3 . I v3 k s E , i s Not Write in Space Below( FOR COUNTY AND STATE DEPARTMENT USE ONLY ,f Application `Fees Paid: State 1 Country ` Date --a ' -,sued/ & (date) L Issuing Agent Name ~ ~ -.,J~ : _ 'es .rNo State Valid# Date Recd `%ite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 copy) 4. Plumber (canary copy) Revised Date 7/1/78