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Parcel 014-1000-90-000 03/21/2006 09:49 AM
PAGE 1 OF 1
Alt. Parcel 1.31.15.7 014 - TOWN OF FOREST
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
SANDRA CORMICAN O - CORMICAN, SANDRA
I
3146 205 AVE
GLENWOOD CITY WI 54013
i
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 3146 205TH AVE
SC 1127 CLEAR LAKE
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 1 T31 N R1 5W SW NW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
01-31 N-1 5W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/28/2005 815200 2950/230 TI
07/23/1997 1169/524 QC
07/23/1997 853/44
07/23/1997 826/569 > /~<'Y -~'t Vii ~7
2005 SUMMARY Bill Fair Market Value: Assessed with: '
94564 117,000
Valuations: Last Changed: 10/17/2005
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 2.000 5,000 37,600 42,600 NO
PRODUCTIVE FORST LANDS G6 38.000 76,000 0 76,000 NO
Totals for 2005:
General Property 40.000 81,000 37,600 118,600
Woodland 0.000 0 0
Totals for 2004:
General Property 40.000 23,150 19,150 42,300
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
!s
State of Wisconsin
DEPARTMENT 01 IATURA
L RESOURCES
• L• P. Voigt
June 2f 1970 M Secretary
'
B 450
MADISON, WISCONS NO
53701
Mr. Bill Kempster
S , General Manager
tansi Scientific Division
Fisher Scientific Company
1231 Honore Street, North
• Chicago, Illinois 60622
Dear Mr. Stansi;
We have received the
area aPProxima results of
proposed buildly 230 feet from percolation tests
8 for the the probable taken in an
Of
these tests Indicate Fisher Scientific Clacetion of the
that ~ acre of ridge pay'
The results
sufficWeient Will to await dispose to of th waste volume.
the anticipated and furrow should be
Before twin revised plans from
g final action on this Dittloff En
Proposal. Sheering Company
Very truly Yours,
Bureau of Water Supply and
Pollution Control
Robert M. Krill, Actin
Chief
RMK:jk Municipal Wastewater Section
cc' Mr- Harold C. Barber
St. Croix Count
Hudson Zoning Administration
Wisconsin 34016
Dittloff
Engineering co
District 5
Y"I
w
,Icago, Ili. 606:'
done: 772-31 cy
o si'rr al~...~~~!
431 E
FISHER SCIENTIFIC COMPANY
4 ers of L.abora!orv APF.ara' i
155 Thirteenth S`-_
'gear Mi Y
This is to inform you ~tY , s
".2 4
now Pi-3 r~ to proceed
z ~~i1t ►»o~~o~ ~ d
biological facility. We finally managed to ! 1
Ite property with good percolation rates.
percolation report and a pencil sketch of the proposed arrow area have been sent to Mr. Krill at the Department of Natural
Iesources in Madison We have received word from him that he ca11
foresee no proble,i•., x `I's 1zer .1111c"i.
vVe are therefore gains' ic) u v t .
!t ~$`f )!)4 F. 3"f7
Proceed with your plans for this profec; -
3Y copy of this letter to Mr. Larry Fly.'?,, a' utu' corporate head-
quarters in Pittsburgh, I am asking him to have our corporate
attorney complete your standard contract and return it to you.
I will probably be coming up to Hudson during the next week or so to
meet with you for further discussion. I'll let you know definitely
when I plan to arrive as soon as I know for sure.
I look forward to seeing you soon!
rr„~h~.~Lr yours
Al Heidrich
Superintendent-Biology
cc: Bill Kempster - Chicago
Larry Flinn - Central Offices
'l'ed Myren - Baldwin, Wiscor-i,:
°fiv,
a r7
g~a •r '~'3 a ~ /Q
• 9
r ' ant: J1 is urns ",es , -ces
4,00 University Ave.
Dear Yr. Will:
. .,.uad nre !nj i of Q o ;oletlor test ..id T)"'1.A o .7.es
e." Kh loopused ria e and furrav s- stem for vastev:ater disposal
for 00 F'iLl ar S Me,a`;ific Co. ,rho wish t,j Ac to in A. uix Co.
LI it,h the p .ola`,ion in this area sunh as it is „ size
of the waten l us Yo,.n reauced to 1 =,n act e, but a an be expanded
A an ante with to woblem PH think it WOUIL ca naue 1.argur.
The n,npLn!, is cr y 8olaL Le use a .'Tl`' ar.., of 800 gQlons of rater
per Sy and most _ he tine it i 11 be around b00 to 500 galloQ
We uoAls i.q thia nrea. sire mach bet:'Lcr t,_.. n ve c`ntinippaLW.
o`_ i t:e G to yjU, ,t ubti oad LhaL the p e vulatliaa r -Le
w.ule tae crev , ere = Dund 30mini tus ti ut thoy up Ath a
0 to 15 minute VIA.
I Lope Sot Oe ea,'sJued Woviation is adequate so t^Pt
Fi ur Lziuntifi ` will le We to gat st:orted on thali long
await ad r jest o .,e can fat s Dma A the peop in "is poverty
DMA je •tion if the nounty on the employment rods.
Ditt i o f f gi neWig C+-omr,'1.a Q11 cJ.u1.plat the 'up al plans
or the ^,':N"•1}=nny and hgve; nhen forwa.rced Q you at once.
t'<,ur irTnedinte a! tention on this Potter All be greatly
1
c,an.i:._;nal approval Lo Lhc ~~7iiJ4,lTly tir6oin ,:'I_il to t1/io o2fice.
77, MLL
M WZ;,n,r n r' + cn ~sr~- to F r
1, in -cc, W22
. &W Twu in ac vancr Or an-- and a-.I asAst, nee that you
truly ours,
a
`J1°oid . Parber, Aping 'ldmi,a.
A
SEPTIC TANK PERMIT NO.
i"
R Y P 0 R T O N S O I L P= R C 0 L A T I 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 S3CTIdK
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 Character of Soil Hours Water Test Time Drop in or Level Inches Minutes
Nusiber Inches Thickness in Inches Since Hole in Hole Ihterval Second to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period One Inch
Example
P - 0 36" To Soil 10" Cla 26" 25 Yes or No 30 1/? 1/? 1/2 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Computs size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 3611 Below o posed Abso tion System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
~
B - 0 721• 72" Black To Soli 12"Clay 16111 Sand 1811• Gravel 241
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCUPANCYs
RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons
FOOD WASTE GRINDERS Yes No DisluFashers Yes No Automatic Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
Is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified 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
DATE SIGNATURE
Wisconsin Department of Health and Seoial SerVA-4
Plb. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Co")
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
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 Automatic Potato Peeler YES NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: Address: License Humbert
MP
Signature of Applioant: MP RSW
Address:
H. (To be Completed by Issuing Agent)
Date of Application Fee Paid Z
Permit Issued (date) Permit Number
Agent (Name) Fort
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.00 for each septic tanic and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be pads payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Correa.)
FEE RECEIVED _ VALID. No. PERMIT N0.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
_ i
5.
' ~ I
j h-
a ,
J 0
k 'f
~t 1
. C
~QrMPr JF
'Elk/
i
INFORMATION REQUIRED FOR SUBMISSION OF PLANS
1. Legal description of property on which septic tank and effluent disposal system
is to be installed.
2. Percolation test data from a minimum of three test holes. Tests are to be conducted
in the area and to the depth of the proposed+eff]Nant absorption system. Where ground
water and/or bedrock conditions exist, the vertical depth from grade level to same shall
be indicated.
3. A detailed plan of the proposed installation specifying the location of the building
served, size and design of septic tank, effluent absorption system with location and
numerical identification of percolation test holes.
4. Indicate on plan lateral distances between septic tank effluent disposal system and
building, well and lot lines.
5. Include complete data on expected use of the building. See Section H 62.20.
L A K F 0,P STREAM 50
P ~
PAGE T 50
TRENCH
J i
75~ r~ . I
S E' E P A G BED 25' ioo 25~
r, Ac W E L L
50 6- --I BLD~~.
I
6, 77.
-1 LI
O~
1000
GAL
50~ 25~
F$E 5 p
WELL SE E P G E I T~
P/
P
i
LOT LI NE
04- P • Peroolation test hole
SAMPLE PLAN DEPICTING SEEPAGE TRENCH, SEEPAGE BED AND SEEPAGE PIT
~l 07~
Plb 60
T, 7
k5 G /1 /V 70F/
NAME p OF BUSINESS
LOCATION i_0 LI~f K)h 4 S U/X
street or highway city or townsshi`p~ county
LEGAL DESCRIPTION I AL N 4;? KJ
OWNER /.5~/L sC l t°A~T/f 1 G Mailing address all
f'.kliL"!i &y. d tt zip l !)l..z a
ARCHITECT OR ENGINEER / A4J b Z- /J Address 17 /).S oE1 ~tiS
2IP ~ ~ y'fJ ~ rT
PLUMBER J~ 0~~4T- blF! IZ1 cAl Address e(VKi
ZIP Od''..9`""
1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed:
Existing building New building Addition
If addition to existing building attach detailed memo for each.
( ) Drive in restaurant . Car spaces
( ) Restaurant . a . . . . . Seating capacity 10 sq. ft./person)
( ) Dining hall . . . . . . . . . . Per meal served Toilet waste Yes No
( ) Motel ( ) Hotel ( ) Cottages . . . Number of units: 2 persons/unit 4 persons unit
TOTAL NUMBER OF UNITS
( ) Churches . . . . . • Number of persons Kitchen Yes No
( ) Bar or cocktail lounge . . . . Seating capacity (10 sq. ft./person)
( ) Nursing or rest home . . . Number of beds
( ) Mobile home park . . Number of units - dependent (camper trailer)
- nondependent (mobile home)
( ) Retail store • . . . . . Number of employees Number of customers (10 sq. ft./person)
( ) Service station . . . . . Number of cars served daily)
( ) School • • • • • • • • . Number of classrooms Meals served Yes No
Showers provided Yes No
( Factory or office building . . Number of persons (total all shift-s`~-
( ) Residence • • . • • • • Number of bedrooms
( ) Apartments . . . . . . . . . . Number of bedrooms
( ) Other . . . . . . . . . . . . . Specify
2. Indicate whether or not the following facilities are oonneoteds Food waste grinder . . . . . Yes No
Dishwasher • . . . . . . . . Yes No
Automatic clothes washer Yes No
3. Fill in the appropriate information for the following as indicated: t 1~ 4) r ?
Septic tank capacity planned 0q, TOTAL Septic tan1c capacity required
Percolation test results - ATTACH PERCOLATION TEST REPORT SHEET
Seepage trench bottom area planned width linear feet depth
Seepage bed area planned width linear feet depth ^f
Seepage pit planned outside diameter depth below inlet depth
Seepage trench bottom area required width linear feet depth
Seepage bed area required width linear feet 4' ;i depth a
Seepage pit required 4044 outside diam'e'~tde~ below inlet ~
Signature of person completing forms STATE DIVISION OF HEALTH, PLUMBING SECTION
P. 0. Box 309, Madison, Wisconsin 53701
Address # Approved: /)1107 P)
_ ZIP 7n _
Dates Dates DEC THIS APPROVAL IS BASED ON STATE PLUMBING
CODE REQUIREMENTS AND DOES NOT EXEPIPT THE
INSTALLATION FROM CITY, VILLAGE, TOWN-
SHIP OR COUNTY REGULATIONS OR PERMIT
(OVER) REQUIREMENTS.
I
Percolation Test Procedure
(1) Type of hole:
Dig or bore at least three vertical holes, 4 to 12 inches in diameter, in the area
of and to the depth of the proposed seepage pit or drainage field. (Contact the
Division of Health for special consideration of tests in newly filled areas.)
(2) Preparation of hole:
Roughen the sides and bottom of the holes with a sharp pointed instrument to
expose the natural soil. Remove the loose material from the bottom of the holes and
place two inches of coarse sand or gravel in the holes.
(3) Saturation and swelling of soil:
(a) The hole shall be carefully filled with clear water to a minimum depth of
12 inches over the gravel, refilling if necessary or by supplying a surplus reservoir
of water such as an automatic siphon, so the test hole is filled with water to a
depth of 12 inches over the gravel for a period of at least four hours. Water
remaining in the hole after four hours shall not be removed. The soil shall be
allowed to swell not less than 16 hours or more than 30 hours so that it will
approach the conditions that will exist during the wettest seasons of the year.
Immediately after the swelling period the percolation test shall proceed as specified
in Sections 4 (a) and (b) below.
(b) In sandy soils containing little or no clay carefully pour 12 inches of
water over the gravel. If this water seeps away in ten minutes or less repeat the
procedure. If the second filling of 12 inches of water seeps away in ten minutes
or less the test can proceed immediately as specified in Section 4 (c) below.
(4) Percolation rate measurement:
(a) Any soil which has sloughed into the hole shall be removed. The water level
shall be adjusted to a depth of not more than six inches above the gravel and the
drop in water level shall be measured from a fixed reference point at intervals of
30 minutes for a period of four hours, refilling the holes with water to a point
not over six inches above the gravel when the hole becomes nearly empty. The test
may be terminated in less than four hours if two successive readings do not vary
more than 1/16 of an inch. Adjustment of the water level shall not be made during
the last 3 measurement periods except to the limits of the last measured water
level drop. The drop in water level that occurs in the last 30 minute interval shall
be used to calculate the percolation rate.
(b) When the first six inches of water seeps away in less than 30 minutes after
the soil swelling period the time interval between measurements shall be taken as
ten minutes and the test run for one hour. The drop in water level that occurs
in the last ten minute period shall be used to calculate the percolation test.
(c) If the second filling of 12 inches of water over the gravel as specified
in Section 3 (b) seeps away in ten minutes or less add water to the hole to a
point not more than six inches over the gravel and from a fixed reference point
measure the drop in water level at ten minute intervals for a period of one hour,
refilling the hole when necessary to a point not over six inches above the gravel.
In cases where the six inches of water above the gravel seeps away in less than
ten minutes a shorter test interval should be used. The final water level drop
shall be used to calculate the percolation rate.
In no _case shall more than six inches of water be above the gravel during the
percolation test.
Plb. X43 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 0 R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECTION
P.O.Box 309, Nadison,'Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
J fa `
NAME PROPERTY ADDRESS L, /fc7 i- X
LOCATION (Check One) City Village Town County J C ~i
City or Township T
WATER SUPPLY FROMt Public Utility Cooperative Private Well
SEWAGE DISPOSAL INSTALLED BYs Address Date
SEPTIC TANK SIZE Material Percolation & Soil Borings Test Date
EFFLUENT DISP.: Tile Size No. Lin. Ft. Trench Width Depth of Tile
Seepage Beds Length Width Depth of Tile
Seepage Pit: Outside Diameter Liquid Depth
TYPE OF OCCUPANCYs
RESIDENCE: Number of Bedrooms OTHERS (specify) Number of Persons
FOOD WASTE GRINDERS Yes No Dishwasher: Yea No Automatic Clothes Washers Yes - No
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted overnight in Minutes Last Period Last Period Period Onerlnoh
Example
P- C 36" To Soil 011. Clay 26' 25 es or no 30 142 1 2 1 60
20
AI-2 1~ -51
RECCRD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
SO I L B 0 R I N G S- Minimum 361"Below Proposed Absorption System
Test Total Depth De nth to Ground Water
Number Inches Observed Estimated Character of Soil with Thickness in Inches
Example
B- 0 72" 72" Black To Soil-1211% Cla 18". Sand 18" Gravel 24"
J
C 91
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
I. the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified 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.
;-1~ r11A%Yt~.
NAME
0),L4 L -d~ TITLE
(Type or Print)
EF.GISTRATION NO. or MASTER PLbMBER LICENSE NO.
ADDRESS//
DATY l J SIGNATURE
i
Percolation Test Procedure
(1) Type of hole:
Dig or bore at least three vertical holes, 4 to 12 inches in diameter, in the area
of and to the depth of the proposed seepage pit or drainage field. (Contact the
Division of Health for special consideration of tests in newly filled areas.)
(2) Preparation of hole:
Roughen the sides and bottom of the holes with a sharp pointed instrument to
expose the natural soil. Remove the loose material from the bottom of the holes and
place two inches of coarse sand or gravel in the holes.
(3) Saturation and swelling of soil:
(a) The hole shall be carefully filled with clear water to a minimum depth of
12 inches over the gravel, refilling if necessary or by supplying a surplus reservoir
of water such as an automatic siphon, so the test hole is filled with water to a
depth of 12 inches over the gravel for a period of at least four hours. Water
remaining in the hole after four hours shall not be removed. The soil shall be
allowed to swell not less than 16 hours or more than 30 hours so that it will
approach the conditions that will exist during the wettest seasons of the year.
Immediately after the swelling period the percolation test shall proceed as specified
in Sections 4 (a) and (b) below.
(b) In sandy soils containing little or no clay carefully pour 12 inches of
water over the gravel. If this water seeps away in ten minutes or less repeat the
procedure. If the second filling of 12 inches of water seeps away in ten minutes
or less the test can proceed immediately as specified in Section 4 (c) below.
(4) Percolation rate measurement:
(a) Any soil which has sloughed into the hole shall be removed. The water level
shall be adjusted to a depth of not more than six inches above the gravel and the
drop in water level shall be measured from a fixed reference point at intervals of
30 minutes for a period of four hours, refilling the holes with water to a point
not over six inches above the gravel when the hole becomes nearly empty. The test
may be terminated in less than four hours if two successive readings do not vary
more than 1/16 of an inch. Adjustment of the water level shall not be made during
the last 3 measurement periods except to the limits of the last measured water
level drop. The drop in water level that occurs in the last 30 minute interval shall
be used to calculate the percolation rate.
(b) When the first six inches of water seeps away in less than 30 minutes after
the soil swelling period the time interval between measurements shall be taken as
ten minutes and the test run for one hour. The drop in water level that occurs
in the last ten minute period shall be used to calculate the percolation test.
(c) If the second filling of 12 inches of water over the gravel as specified
in Section 3 (b) seeps away in ten minutes or less add water to the hole to a
point not more than six inches over the gravel and from a fixed reference point
measure the drop in water level at ten minute intervals for a period of one hour,
refilling the hole when necessary to a point not over six inches above the gravel.
In cases where the six inches of water above the gravel seeps away in less than
ten minutes a shorter test interval should be used. The final water level drop
shall be used to calculate the percolation rate.
In no case shall more than six inches of water be above the gravel during the
percolation test.
SEPTIC TANK PERMIT NO.
Plb. #43
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 0 R I N G S
TO
DIVISION OF HEALTH - PWMBING SECTION
P.O.Box 309, Madison, Wis. 53701
pursuant to H 62.20, Wis. Administrative Code
NAME PROPERTY ADDRESS
LOCATION (Check One) City _ Village Town - County
City or Township
WATER SUPPLY FROM: Public Utility Cooperative Private Well
SEWAGE DISPOSAL INSTALLED BYs Address Date
SEPTIC TANK SIZE Material Percolation & Soil Borings Test Date
EFFLUENT DISP.: Tile Size No. Lin. Ft. Trench Width Depth of Tile
Seepage Beds Length Width Depth of Tile
Seepage Pit: Outside Diameter Liquid Depth
TYPE OF OCCUPANCY:
RESIDENCE: Number of Bedrocros OTHER: (specify) Number of Persons
FOOD WASTE GRINDER: Yes - No Dishwashers Yes No Automatic Clothes Washers Yes No
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted overnight in Minutes Last Period Last Period Period One Inch
Example
P- 0 36" To Soil 10" Cla 26' 25 es or no 301/2 1 2 1/2 60
'0 ~6
RECORD DATA FROM MINIMUM OF 3 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 36t"Below Pro osed Abso tion System
Test Total Depth Depth to Ground Water
Number Inches Observed Estimated Character of Soil with Thickness in Inches
Example
B- 0 7211 72" Black To Soil-1211: Clay 18". Sand 18111 Gravel 24"
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
I. the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded-aqd location of test holes are correct to the best of my knowledge and belief.
1 cy { _v r
NAME TITLE
(Type or Print) s
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS Ff lG t''11P~~✓ 0_ iJ
f r~
DATE' SIGNATURE
i
1
4 '
RLPCRT CF INSP'7CTICN-XINDIVUAL S TIEiTaGE-DISPOSAL SYSTEM
PRIPitAY TR 1:~TMZNT consists of Septic Tankj Cther (Describe)
SEPTIC TANK: Distance from: Well, ft., Lot Line ft. Building ft.
High watermark ft. 12% or greater slope ft. Wetland ft.
Cistern ft. No. compartments Liquid capacity,',?, ,a
EFFLUEINT DTSPCS_ L SY07M consists of Tile field. Seepage pit (s).
Seepage Pit or Tle Field: Distance from: Well ft. Building_ft.
Lot Line ft. Cistern ft. Hirsh Watermark of water course ft.
Slope 1?_ or great r ft. Wetland ft.
Total length of tile linesZLIft. Number of lines Length o each
line.C ft. Distance between lines J ft. Width of trench/
Total effective absorption area of trench bottom / 1i Sr. ft.
Depth of filter material below the /-n in. Depth of filter material
over tile ,,,I in. Cover over filter material
Depth of tile below finished grade in. Slope of trench bottom in.
per 100 ft. Depth of bedrock.- ft. Depth to ground water"-W- ft.
Number of Pits Cutside diameter ft. Depth below inlet ft.
Lining material Gravel around pit,: Yes.
:No. Total sbsorption area so. ft.
Square feet of seepage trench bottom area required
Square feet of seepage pit area required
Inspected by:
Title:
Approved , Date ,19
Rejected , Date _,19-
1A
County, Town of
Cwner~ Xo~;.
Sanitary Permit No. Z// Pronerty Addr=ess
Septic Tank Permit No.z~ L-~ 4:% +subdivision
Plb. EO
3"7p PROJECT DETAIL DATA SHEET
NAME OF BUSINESS LOCATION
street or higiway -city or township county
LEGAL DESCRIPTION
OWNER Mailing address
ZIP
ARCHITECT OR ENGINEER Address/
~ ZIP
PL'uMB_f. Address
ZIP
1. Check appropriate building usage(s) and fill in the information requested opposite
each ,cage 1 i ~ t-d:
Existing building New building Addition
If addition to existing building attach detailed memo for each.
( ) Drive in restaurant Car spaces
( ) Restaurant Seating capacity (10 sq. ft./person)
( ) Dining hall Per meal served Toilet waste Yes No
( ) Motel ( ) Hotel ( ) Cottages Number of units: 2 persons/unit
4 persons/unit TOTAL NUMBER OF UN!TS
( ) Churches Number of persons Kitcheii Yes No
( ) Bar or cocktail lounge Seating capacity (iO sq. ft./person)
( ) Nursing or rest home Number of beds
( ) Mobile home park Number of units dependent (camper trailer) _
nondependent (mobile home) _
( ) Retail store Number of employetis _
Number of customers 710 sq. ft./person)
( } service station Number of cars served (daily)
( ) School Number of classrooms Meals served Yes
No _
Showers provided Yes No
( Factory or office building Number of persons (total 311 shifts
( ) Apartments Number of bedrooms
r
Other Specify
%
2. Indicate whether or not the following facilities are connected:
Food waste grinder Yes No Dishwasher Yes No C"
Automatic clothes washer Yes No Automatic potato peeler Yes
Other . . . (Speci fy) No
3. Fill in the appropriate information for the follo,.+:ng as indicated:
Septic tank capacity planned ~4S
i
Percolation test results ATTACH PERCOLATION TEST AND SOIL BORINGS REPORT SHEET
• i
COMPLETE OTHER SIDE
Y 2t
Seepage trench bottom area planned width
linear feet depth Seepage bed area p 1 ar ned width -d _
linear feet depth
Seepage pit planned _ outside diameter
depth below inlet depth
4. See approved plan for specifications and details.
Signature of person completing form: STATE DIVISION OF HEALTH, PLUMBING SECTION
P. 0. Eo;: 309, Madison, Wisconsin 53701
- .Z- - - L~ f Approved:
--`-f
Address. Date NOV
THIS APPROVAL IS BASED ON STATE PLUMBING
CODE REQUIREMENTS AND DOES NOT EXEMPT THE
Date: - INSTALLATION FROM CITY, VILLAGE, TOWNSHIP
OR COUNTY REGULATICNS OR PERMIT REQUIRE-
MENTS AND SHALL BE VO w IF REVISED WITHOUT
THE WRITTEN APPROVAL OF THE DIVISION OF
HEALTH.
DEPARTMENTAL USE ONLY
6
' Wisconsin Department of Health and Social Services
Pib. #67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Code)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTEbMED COUNTY- y y
Check Onet
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP ~y~~.~ ? Nl~ ~ ~ / J a.~~~
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION / REPLACEMENT ADDITION
MATERIALS: Prefab Concrete cured in .g Steel Other
NUMBER OF TANKS TO BE INSTALLED: y ZtU
E. TYPE OF OCCUPANCY
,Check One: One or Two Family Residence Commercial Industrial Other
(Specify)
Number of Persons to be Accommodated j Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES /Y- NO
Dishwasher YES NO Automatic Potato Peeler YES .Y NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
Name: ~r • 11/d/~~ j Addresss +~J~7t1 L~G"~~i~ License Number:
MP
Signature of Applicant: MP RSW
Address:
i
H. (To 7,7 pleted by Issuing Agent)
Date of Application /w2 Fee Paid $
Permit Issued (date :L- Permit Number 74
Agent (Name) 1 Fort' Llf~
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will forward application, the fee of $1.00 for each septic tanx and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
1. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
I FEE RECEIVED VALID. No. PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT NO. y~ •
R E P O R T O N S O I L P I 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
TO
DIVISION OF HEALTH - PLUMBING S&CTIdN
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 Character of Soil Hours Water Test Time Drop in or Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period Ons, Inch
Example
P - 0 361, To Soil 10/3 Clay 2613 25 Yes or No 30 1 2 1/? 1/2 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 36'3 Below reposed Absorption System
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 7211 7211 Black To Solt 121' C 1813 Sand 181' Gravel 241
RWORD DATA FROM MINIMUM OF 3 BORE HOLES
YPE OF OCCUPANCY:
RESIDENCE: Number of Bedrooms OTHER: (Specify) Number of Persons
D WASTE GRINDERS Yes No Dishwashers Yes No Automatic Clothes Washers Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
Tile Sizs No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: LengthZ Width yZ 0 Depth Tile Size -.Z- No. Lines
Seepage Pits Inside Diameter Liquid Depth
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data reoorded and location of test holes are correct to the best of my knowledge and belief.
NAME 'C7" /i /4~','~ X I -L TITLE Gt Y
Type or Print
N
REGISTRATION NO. or MASTER PLUMBER LICENSE NO.
ADDRESS
DATE SIGNATURE